Medical Standards Research Coordinator
US-NM-Albuquerque
Careers (External)
Req #: 47237
Type: Full Time
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Overview: Now hiring a Medical Standards Research Coordinator Responsible for the research, analysis, planning, implementation, evaluation, and development of PHP Medical policies, clinical criteria, and technology assessment processes that promulgate PHP/PIC medical coverage policies and benefit determination guidelines How you belong matters here. We value our employees' differences and find strength in the diversity of our team and community. At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members. Why Join Us * Full Time - Exempt: Yes * Job is based at Rev Hugh Cooper Admin Center * Work hours: Days * Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees. Ideal Candidate: Bachelors in related field. Experience in coding, researching medical coverage, and policy development. Three to five years experience in CMS Coverage guidelines research and general medical literature Responsibilities: * Develops medical policy (e.g. cancer treatment, transplants) and benefits (e.g. durable medical equipment, ambulance services) * Scans the available literature for emerging technologies and/or new uses for existing technologies * Researches recent peer-reviewed clinical literature, CMS guidelines, related public domain literature, and PHP/PIC licensed sources such as Milliman and Hayes.Generates recommendations from research for presentation to related PHP/PIC clinical quality committees (such as TAC, MPC, CQC) Develops, organizes and maintains coverage documents for electronic and hard-copy records. * Scans medical literature for emerging technologies. * Reviews benefits/services, related financial impact and potential coverage changes by managing the cross departmental Medical Policy Committee (MPC) * Maintains the on-line Medical Policy Manual and ensures completeness, accuracy and ease of use * Researches and resolves benefit related questions for internal staff, which includes heading ad-hoc work groups and conducting special sessions for coverage issues requiring immediate attention. Develops and carries out project plan for oversight of delegated operational functions. * Monitors and maintains compliance with state, federal, NCQA and contractual requirements relating to benefits and coverage issues. * Maintains relationships with PHP/PIC commercial, Medicaid, and Medicare compliance officer in relation to benefits and benefit related documents. * In collaboration with Product Development implements benefit changes, both standard and non-standard via the above mentioned committees. * Regularly reviews new HCPCS and CPT codes via the Health Services Coding/Medical Record team lead configuration, and finance, as necessary. Qualifications: * Licensed RN, or other Health Care Professional with experience in coding, researching medical coverage, and policy development. * Bachelors in related field, or two to three years college level courses. * Three to five years experience in CMS Coverage guidelines research and general medical literature. * Excellent written and verbal communication skills. * Detail and results oriented. Experience with CPT, ICD-9-CM, HCPCS Level II coding rules and regulations, Medicare, AMA, and industry standards is a plus. * Candidates must possess strong organizational, research, and writing skills and a high level of energy as well as a strong commitment to excellence. * The ability to demonstrate critical thinking and ethical behaviors is required. * Must be highly self-motivated and have demonstrated ability to perform clinical research, summarize study results, review and summarize literature which describes evidence-based conclusions and industry practices. * Must be very comfortable with PC-office tools. Education: Essential: * Associate Degree
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