Medical Policy Specialist researches and designs criteria to determine policy guidelines used in review of patient cases to ensure only medically appropriate services are reimbursed. Recommends a policy and process that ensure alignment with company guidelines and nationally accepted medical/coding standards. Being a Medical Policy Specialist establishes the proper codes to use for claims processing. Responds to questions from medical staff and communicates details about policy and guidelines. Additionally, Medical Policy Specialist requires a bachelor's degree. Typically reports to a supervisor or manager. Requires Registered Nurse RN. The Medical Policy Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Medical Policy Specialist typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Responsible for providing leadership and broad strategic direction in the area of Senior Services particularly PPO and HMO Medicare and Medicare Advantage lines of business. Responsible for corporate policy interpretation, recommendation and review within recognized area of responsibility.
"Qualifications"
Departmental Preferences / Summary:
Five (5) years of experience and in utilization review with strong understanding of CMS regulations not limited to NCD and LCD, Medicare product cycle and benefit design requirements.
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