• Job Description

  Req#: R10196

  We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

  Residency in or relocation to Louisiana is preferred for all positions.

  POSITION PURPOSE

  This position is responsible for completing the Medical Policy activities outlined in BCBSLA’s Medicare Advantage Medical Policy Development Policies & Procedures locating, tracking and documenting information and working closely with the Medical Directors and Manager of Medical Policy and Medical Appeals to ensure successful fulfillment of the program’s mission and to promote its growth and development within Blue Cross and Blue Shield of Louisiana. In addition to above duties, this position will also support on an as needed basis support the Medical Policy Project Analyst position when medical policy volume is elevated or the primary Analyst is on leave. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.

  NATURE AND SCOPE

  • This role does not manage people
  • This role reports to this job: MANAGER, MEDICAL POLICY
  • Necessary Contacts: Benefits Administration, Network Administration, Information Technology, providers, and any external or governmental regulatory agencies as required. Works closely with all Medical Directors/Associate Medical Directors, Provider Audit, Legal Department, Claims and all members of Medical Management. Also acts as Liaison between Blue Cross Association medical policy staff and BCBSLA Medical Policy Director.

  QUALIFICATIONS
  
  Education

  • Bachelor's in nursing, business administration, healthcare, computer science or a related field is required or
  • In lieu of a degree an RN license is required or
  • In lieu of a Bachelor's degree an Associate's degree in nursing with a license to practice in Louisiana as well as two years of relevant experience in clinical research methods such as epidemiology, psychology, biostatistics, or health informatics is required or
  • In lieu of a degree an LPN license to practice in Louisiana as well as two years of relevant experience in clinical research methods such as epidemiology, psychology, biostatistics, or health informatics is required or
  • Four years of directly related experience can be used in lieu of a Bachelor's degree.

  Work Experience

  • 3 years of direct patient care/clinical experience is required
  • Requires experience reading and evaluating clinical research methods and processes and interpreting clinical study reports, health authority reports, and clinical summaries.
  • Experience with Adobe software is required.
  • Blue Advantage experience is strongly preferred.

  Skills and Abilities

  • Must have knowledge of claims processing systems.
  • Staff level experience in Quality Improvement/Management and/or Managed Care activities is required.
  • Basic knowledge of coding principles to include ICD 10, CPT and HCSPCS is required.
  • Working knowledge of Microsoft Access database formatting, Word, Excel experience is required.
  • Must demonstrate a clear understanding of the healthcare delivery system including facilities and services available and data processing needs.
  • Excellent analytical, written and oral communication and interpersonal skills are required.
  • Must demonstrate excellent technical writing skills along with problem-solving skills.
  • Must be able to work independently under deadlines and handle heavy workloads accurately.

  Licenses and Certifications

  • Health Services\RN - Registered Nurse - State Licensure And/or Compact State Licensure to practice in Louisiana is required
  • Medical coding certification (CPC, CCS, CMC) is preferred

  ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

  • Evaluates and researches new treatment options, procedures, devices, drugs and biological products as needed to support the Medical Directors in developing appropriate Medicare Advantage medical policies.
  • Writes a wide variety of technical policies and creates documentation for a wide range of uses associated with medical policies. Responsible for display of graphics and the production of medical policy documents. Writes draft medical policies for Blue Advantage MA and Primewell Utilization Management Committee functions specific to medical policies and supports work within various organizational departments to implement approved policies.
  • Coordinates the Blue Advantage MA and Primewell Utilization Management Committee functions specific to medical policies and supports work within various organizational departments to implement approved policies.
  • Establishes and maintains systems to track information related to medical policy review activity using Medical Policy Management System.
  • Responsible for interface between medical policy unit, claims processing systems and other business areas to enable accurate adjudication of medical policy claims.
  • Responsible for development of clinical criteria used by other units to review requests for medical services addressed in medical policies.
  • Responsible for reacting rapidly with daily internal customer interchange and multi-faceted tasking while providing insights and independent thought and advice on medical policies based on research.
  • Serves as a resource to BCBSLA Medical Directors for complex issues that require additional research and is liaison to BCBSA medical policy contracts.

  Additional Accountabilities and Essential Functions
  The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

  • Perform other job-related duties as assigned, within your scope of responsibilities.
  • Job duties are performed in a normal and clean office environment with normal noise levels.
  • Work is predominately done while standing or sitting.
  • The ability to comprehend, document, calculate, visualize, and analyze are required.

  #LI_MS1

  An Equal Opportunity Employer

  All BCBSLA EMPLOYEES please apply through Workday Careers.

  PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

  Additional Information

  Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

  If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

  In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

  Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

  Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

• About the company

  Blue Cross Blue Shield Association is a federation of 36 separate United States health insurance companies that provide health insurance in the United States to more than 106 million people.

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