RN Med Policy Development​/Research Specialist; UM - REMOTE-AZ

Work Location and Hours

Hybrid workforce strategy “Workability” offers flexibility with how and where employees work. Positions are classified as hybrid, onsite or remote. The following classifications drive current minimum onsite requirements:

• Hybrid People Leaders – must reside in Arizona; required to be onsite at least twice per week.
• Hybrid Individual Contributors – must reside in Arizona; required to be onsite at least once per week.
• Hybrid 2 (Operational Roles such as but not limited to Customer Service, Claims Processors, and Correspondence positions) – must reside in Arizona; required to be onsite at least once per month.
• Onsite – daily onsite requirement based on the essential functions of the job.
• Remote – no onsite requirement; leadership may request presence onsite for business reasons.

Onsite requirements may change in the future based on business need and job responsibilities. Most employees should expect onsite requirements of at least once per week. This position is hybrid within the state of Arizona only.

Perform medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.

• Level 1
  • Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel.
  • Develop and revise coverage guidelines and criteria as requested.
  • Communicate medical policy information in protocol format to all areas of BCBSAZ requiring this information.
  • Participate as a contributing member on the Medical Policy Panel and on the Clinical Coding Governance Committee (CCGC).
  • Maintain a thorough knowledge of all BCBSAZ medical coverage guidelines and other policies.
  • Facilitate external consultant reviews concerning a coverage guideline or new technology, including initiating the consultation and summarizing the external review.
  • Communicate medical policy information in protocol format to healthcare providers upon request.
  • Perform basic level code review.
  • Meet quality, quantity and timeliness standards to achieve individual and department performance goals.
  • Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.
• Level 2
  • Recognize necessity of an external consultant review and summarize and report information to management.
  • Perform intermediate code review and recommend recommendations to the CCGC for integration into benefit programming.
  • Provide training, development and support of grade level I staff under an established training program.
• Level 3
  • Perform advanced code review and provide recommendations to the CCGC for benefit programming.
  • Initiate research from resource materials, summarize and report information to management for further action.
  • Provide training, development and support of grade level I and II staff under an established training program.
• Level 4
  • Assist manager with the implementation of daily operations regarding guideline development and revisions, staff supervision, and necessary coaching.
  • Assist manager with coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
  • Assist manager with monthly, quarterly and annual reporting to the Director.
  • Assist manager with coordination of annual review(s) of MCG, eviCore and/or Change Healthcare Inter Qual criteria updates.
  • Assist manager with oversight to staff for monthly review of BCBS Association Medical Policy and Reference Manual updates.
  • Assist manager with initial training and instruction for both professional and technical staff.
  • Conduct or participate in internal committees that further the goals of BCBSAZ and the Medical Policy & Technology Department.
  • Provide training, development and support of grade level III staff under an established training program.
• All levels include the ability to perform the essential functions of any lower levels.

The position has an onsite expectation of one day per week and requires a full-time work schedule of at least 40 hours per week,…