PURPOSE: Reporting to the Vice President, Chief Medical Officer, the Director, Health Care Policy is responsible for research, development, maintenance, and implementation of evidence-based, clinically sound, jurisdictionally compliant corporate medical and claims adjudication policies and technology assessments. In addition to providing support on clinical policy, this position is responsible for ensuring CareFirst clinical programs are meeting all legislative and regulatory requirements, providing support and expertise in medical benefit design, handling escalated issues of a clinical or policy nature that come from the Strategic Business Units and shaping Executive Management’s perspective on key technologies. In brief, the function of this role is to ensure that CareFirst is on the cutting edge of medical and payment policy to accelerate the emergence of a value-based health care system.
The incumbent drives and oversees the ongoing thorough research, documentation of research, and promulgation of new and existing policies to appropriate internal and external customers while directing the collaborative evaluation, revision and maintenance of on-line claims adjudication. He or she functions as the in-house expert for medical and payment policy, pricing, and coding.
In addition, the incumbent represents the Medical Affairs Division on matters of health policy in order to influence subscriber quality medical care and positive relations with providers and the community. The role requires collaboration with several key stakeholders across the organization as well as externally including; Multiple business areas within the CareFirst Medical Affairs division (Central Appeals, Provider Relations, Care Management, Compliance, and others. Strategic Business Units, Sales and Marketing, Communications, Legal, Government Mandates, and others Core Business Partners
Under the general direction of the Vice President & CMO the Director, Health Care Policy’s responsibilities and accountabilities include, but are not limited to, providing direction, leadership, and oversight for the following functions:
Corporate Medical Policy Administration: Responsible for Directing the research, development, maintenance and implementation of corporate medical and claims adjudication policies. Collaborates with Medical Directors, Federal, State and Local entities, internally and externally to notify and interpret health care policy for new or revised benefit structures.
Medical Technology Assessment: Accountable for directing up to date assessment of both FDA approved and emerging new medical treatment technologies and protocols.
Ensures that accurate and timely information is provided based on in-depth review of the issue, current sources, and corporate philosophy and standards.
Oversees the informed review of current benefit contracts and recommendations for new or revised benefit structures.
Oversees the authoring of articles and providing educational programs as requested related to health policy.
Responsible for timely notification and explanation of key policy changes to appropriate internal and external customers.
Systems Oversight: Accountable for directing corporate systems processes and strategies that involve translation of medical policy into claims adjudication which impacts over 200 million dollars in care cost. Manage Claims software, reviews and customize as necessary, and simultaneously on appropriate platforms in collaboration with other departments. Includes knowledge of ICD-10 and understanding of Claims editing tools
Ensures consistent claims adjudication on all platforms utilizing the appropriate software product. Ensures that new versions/releases of software are thoroughly reviewed, customized as necessary, and implemented simultaneously on appropriate platforms in collaboration with other departments
Accountable for compliance with current medical policies and benefit structures
Ensures that policies/edits that are contractually and jurisdictionally compliant and that system components/files that are accurately and timely maintained
Health Policy Representation: Responsible for representing Medical Affairs Division on matter of health policy in order to influence subscribers, providers and community.
Clinical Consultation: Strategic collaboration with all internal departments (i.e. Central Appeals, Legal, Provider Relations, Corporate Communications, Government Affairs, and Care Management) and external customers (including physicians, non-physician providers, facilities, vendors) regarding coding practices, policy interpretation and new/existing technology.
Reimbursement Policy: Responsible for directing the research, development, maintenance and implementation of corporate reimbursement policies.
Directs the strategic exploration of opportunities and recommending and effecting change for future initiatives or partnerships to improve relationships with internal and external customers.
Team Leadership and Administrative Oversight: Directs the day-to-day activities of the Health Care Policy and Technology Assessment Department, including directing, coaching, and guiding associates in order to implement departmental, divisional, and organizational mission/goals. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.
Required Knowledge and Experience:
Health Care Policy expert with a minimum of 10 years’ experience in a health insurance environment. If a nurse, Bachelor of Science in Nursing or related health care discipline.
At least 5 years of prior experience managing human and fiscal resources, and policy development and implementation in a health care setting.
Professional coding certification by a national organization (i.e., AAPC or AHIMA).
In-depth knowledge and understanding of operational, legal/ethical, and system compliance requirements related to health policy development and implementation.
In-depth knowledge of standards and laws and regulations related to the health care environment.
In-depth knowledge of medical and claims policy development;
In- depth knowledge of reimbursement policyThe following competencies are required to perform the responsibilities successfully:
Required Skills and Abilities:
Clinical Quality and Process Improvement
Evidenced-based Research, Evaluation and Interpretation
Budget and Fiscal Management
Written and Oral Communication/Presentation Skills
Influencing and Negotiating
Proficiency in Microsoft Office Suite
Navigation of mainframe computer systems, including database software packages
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Preferred: Master’s degree in nursing, or other health-related discipline or MBA. Claims operations/medical review experience in a health insurance setting. Two or more years’ experience with Medicare Advantage or Medicaid.
Internal Number: 12736
About CareFirst Blue Cross Blue Shield
CareFirst is the health care marketplace leader in more ways than one. We are the largest health care insurer in the Mid-Atlantic region, employing more than 5,000 associates and serving nearly 3.4 million members in Maryland, the District of Columbia and Northern Virginia.We are also innovation leaders – our associates are continually finding creative and effective ways to deliver greater value and service to our members and improve the quality of life in our communities. The new normal for the health care industry is constant change and evolution and CareFirst strives to drive the future of health care through our advanced solutions.We promote learning and development by encouraging and supporting our associates to invest in their own learning and development. We are guided by a powerful set of values that inform and influence our interactions with each other, our members and our community.