Mgr, Medical Policy vacancy at Highmark in Pittsburgh

Highmark is currently interviewing Mgr, Medical Policy on Tue, 06 Aug 2013 15:14:57 GMT. Summary of Job Responsibilities: * This position is responsible for the development, maintenance, revision, and promulgation of corporate medical policy, for all commercial medical-surgical products (traditional, managed care, Major Medical, FEP) and Medicare Advantage products. * This position also oversees the corporate Diagnosis Code Database and the Professional Consultant Network. * The...

Mgr, Medical Policy

Location: Pittsburgh Pennsylvania

Description: Highmark is currently interviewing Mgr, Medical Policy right now, this vacancy will be placed in Pennsylvania. For complete informations about this vacancy opportunity please give attention to these descriptions. Summary of Job Responsibilities:

• This position is responsible for the development, maintenance, revision, and promulgation of corporate medical policy, for all co! mmercial medical-surgical products (traditional, managed care, Major Medical, FEP) and Medicare Advantage products.
• This position also oversees the corporate Diagnosis Code Database and the Professional Consultant Network.
• The incumbent must have comprehensive knowledge of policy application in a claims processing environment, product benefits and limitations, provider contracts, and reimbursement methodologies.
• This position must also be knowledgeable about national and regional Medicare policies and regulations, in order to accurately manage policies for the Medicare Advantage products.
• This position routinely interacts with all levels of staff within the company, including the Chief Medical Officer and other senior and executive levels, as well as regular communications with professionals external to Highmark (e.g., Pennsylvania Medical Society, Professional Consultants, network providers).

Required Qualifications:

• A bachelors degree or equivalent training in Health! or Business Administration is required. A degree in Nursing is preferred. Three (3) to five (5) years of health insurance experience is also preferred, as in Operations, Contracting, and/or Medical & Payment Policy Administration.

Other Qualifications:

• The incumbent must demonstrate a thorough knowledge of the inter-relationship between medical policy, member benefit contracts, provider contracts, and claims operations. This includes in-depth knowledge of procedure and diagnosis codes, reimbursement methodologies, OSCAR processing capabilities and edits, standard contractual benefits, exclusions and provisions for all medical-surgical products, medical terminology, and BCBSA and CMS guidelines.
• In addition, this position requires strong decision-making ability; strong interpersonal skills; exceptional communication skills; and the ability to manage a professional staff dealing with significant corporate responsibilities.
• Som! e travel is required.
• This position is responsible for supporting the coordination of medical policy between Highmark and other affiliated entities (e.g., IBC, BCNEPA and Mountain State Blue Cross Blue Shield). With IBC and BCNEPA, the company maintains Joint Operating Agreements and other business relationships requiring interaction and support for their handling of Highmark's network providers. (For example, IBC uses our Participating and PremierBlue Shield networks as "wraps" around their GPPPN network. The incumbent supports IBC's policy-related needs in maintaining these "wrap" relationships).
• Mt.State requires significant support as a Highmark affiliate. The incumbent manages integration and maintenance issues for Mt.State's commercial and Medicare Advantage business, with minimal support from Mt.State's small staff.
• The incumbent also maintains direct care cost savings in the claims processing environment. Annual savings from application of! the more significant policy guidelines exceeds $98 million. This posit! ion is responsible for maintaining satisfactory savings levels through contractually-based, fully automated policy edits in OSCAR.

Highmark is an Affirmative Action/Equal Employment Opportunity (AA/EEO) employer.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Highmark.

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This vacancy starts available on: Tue, 06 Aug 2013 15:14:57 GMT

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