As Senior Managed Care Policy Analyst, you will manage the accurate representation of medical rules/edits from any source. You'll build and use all tables and work with clients regarding Technical Support Issues identified. You may review and make recommendations regarding Level I and Senior coding, placement, and logic. You'll be responsible not only for assisting with building tables associated with new products or technology but also the release and review of content into production for client use. You'll make recommendations and assist with data/tables for new products. You will report to the Senior Director, Compliance Data.
You will:
- Identify necessary and potential changes to existing medical rules through review of current and historically available hardcopy medical policies, transmittals and bulletins. This includes revision and retirement of existing policies and the addition of new policies.
- Extract information from resources and translate information needed to form appropriate logic for rules, documentation and quality assurance review. Complete Clinical Transaction Engine table builds (used by eCN Medical Necessity and ClaimSource) with completion of integrity checks Review of edit modification for medical procedures for clear representation varying levels of ICD-10-CM diagnoses.
- Assign CPT/HCPS codes for PreCertification product table(s) where contractor supplies narrative condition only. Also participate in review of National NCD's for National policies, assigning appropriate diagnosis and procedural codes to be reviewed by Director and for strategic inclusion into Medicare medical edits.
- Independently prepare and make appropriate adjustments to any data editorial for release to production
- Prepare reports and documents for Director review including coding trends, documentation requirements, related payer changes and concerns.
- Complete reviews of medical policies and publications and its integration into the required database. Identify patterns of improper coding or errors in policies and publications and can resolve and recommend alternate codes, or code representation is appropriate table(s) (Diagnosis, CPT/HCPCS, CCI_Edits)
- Complete in-depth, independent reviews of issues forwarded byCompliance Support. Compose responses and discuss with clients.
- Maintain all medical rules editorials in the appropriate database using programmatic tools.
- Analyze data and draw conclusions.
- Be responsible for accurate research of resources that update critical information on a scheduled basis. Stay up to date with current coding issues.