Job Details

The Medical Policy Research Nurse/Coder is responsible for developing and maintaining medical, drug, and claim payment policies that conform to accepted medical practice and reimbursement standards and contributes to the analysis and implementation of medical code updates.

Job Description

Primary Responsibilities:

• Develops and maintains new and existing medical necessity, Drug, and claim payment policies conforming to accepted medical practice standards and under evidence-based principles of medicine, Company benefit structure and reimbursement rules, state and federal mandates, and other appropriate sources
• Contributes to the development and enhancement of documentation, tracking tools, and process flows 
• Maintains documentation necessary for systems analysts to configure and enforce policy positions and rules 
• Participates in relevant workgroups and provides deliverables as necessary
• Successful and timely completion of assignments per department and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner.
• Maintains detailed knowledge of the status of all assignments and routinely updates the members of the management team as appropriate
• Performs all other duties as assigned.

Supervisory Responsibility:

N/A

Work Environment:

This job operates in a remote setting. 

HPP allows employees to work remotely based on its determination that a remote work arrangement is appropriate based on HPP’s business needs and the employee’s ability to perform the job remotely in an effective manner.  Should those business needs change, HPP reserves the right to change the remote working arrangement at any time, in accordance with HPP’s Flexible Remote-Working Policy. HPP will provide a minimum notice of 60 days of any change in the remote working arrangement,

Physical Demands

While performing the duties of this job, the employee is regularly required to talk and hear.

Travel

0% of work week, unless otherwise required for business needs.

Work Location

This position is available to work from home; in accordance with our Flexible Remote-Working Policy, who you will be required to acknowledge and sign upon hire.

Job Requirements:

Education and Experience:     

• Bachelor’s Degree required
• 5 years’ experience in insurance industry in areas of Benefits Administration, Health Care Management or related field.
• RN Current licensure in the state of Pennsylvania
• Certified coder preferred.
• Experience with medical billing, coding, and/or office-based medicine/practices management
• Experience with claims data and/or claims payment preferred
• Knowledge of FDA regulatory requirements for medical devices, drugs and biologics preferred.
• Experience with medical policy development and implementation

Skills/Abilities:

• Must have demonstrated experience working with benefit design process, preferred Medicare and Medicaid
• Ability to mine data and content, develop presentation and communicate concepts
• Excellent communication skills, including the ability to interface with all levels of management
• Detailed oriented with significant knowledge of heath care and public policy
• Demonstrated ability to lead and effectively work with multidisciplinary teams
• Strong problem solving skills
• PC Skills ( Word, excel, power point)
• Ability to function independently with minimal supervision
• Strong analytical and problem solving skills
• Strong organizational skills and ability to manage multiple priorities
• Excellent organizational, time management, presentation, verbal and written communication skills
•  Project management skills are preferred.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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