Policy and Coding Research Specialist

Policy and Coding Research Specialist

Reporting to the Sr. Manager of Utilization Management, Care Management and Quality and working closely with the Senior Medical Director and the Coding and Configuration Manager. The candidate is responsible for providing essential support and information that translates evidence-based medical care into policies and procedures that enable a health plan to function. They will be responsible for reviewing clinical, regulatory and industry resources to maintain knowledge about new and emerging technologies and treatments, payor standards for coverage in similar markets and new CPT and ICD-10/11 and HCPCS codes for configuration and coverage assignment.

This job is remote and requires meticulous work, often self-directed. Collaboration with other members of the team and within the organization is key to success in this role. There is opportunity for growth in the role.

• Reviews clinical resources and external health plan policies for coverage comparisons
• Supports review of CMS-designated codes, coding updates and does timely review of codes initially designated as exclude at launch or experimental/investigational to determine required code designations. Works closely with the Coding and Configuration Manager to accomplish this.
• Does research needed for custom code-configuration lists, such as the Chronic Illness Support Program, to support all lines of business and self-insured employer groups benefit coverage requirements, as applicable.
• Monitors regulatory requirements to ensure appropriate code configuration and coverage.
• Is part of the Utilization Management Team that supports and collaborates with the Clinical Operations Team to ensure appropriate configuration of codes for billing and auditing.
• Participates in the Clinical Code Review, Benefits and other Committees as requested.
• Works with Compliance Team to meet regulatory requirements and stay up to date on legislative initiatives.

• Is responsible for updating policies and guidelines within MCG and maintains the license and relationship with our vendor partner.
• Maintains the licenses and communication with Hayes (symplr) Medical Necessity Guidelines.
• Maintains expert knowledge of ICD-10 and 11, CPT and HCPCS codes and provides education as necessary.
• Understands current Member Benefit Agreements for all lines of business.

• Willingness to support the Utilization Management team with case reviews as needed to maintain compliance.
• Willingness to participate in project work or supportive duties as assigned by the Director of Utilization Management, Care Management and UM Appeals, the Coding and Configuration Manager, or Senior Medical Director.
• Proficient in Microsoft Products, particularly Word and Excel and adaptability to use electronic documentation systems, including Salesforce.
• Excellent English communication and writing skills.
• Familiarity with application of MCG Guidelines.

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well.

Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

• Valid, unrestricted RN (registered nurse) Licensure, Compact or Maine Licensed.
• Minimum of 3 years working in a health plan with relevant experience.
• 2+ years of policy research and development experience.
• Experience in medical necessity reviews within a health plan highly preferred.
• Certified coder, or certification within 6-12 months of hire.