Rules Specialist

POSITION TITLE: Rules Specialist

Supervised by: Medical Necessity Supervisor

Supervises: None

Status: Full- or part-time, hourly non-exempt

Location: This position can be onsite in Independence, OH, or remote / home based

POSITION SUMMARY.

The Rules Analyst is responsible for keeping Medicare policy information accurate and current in the rules database as well as ensuring that all contractor information is available and current in the database.

JOB DUTIES and ESSENTIAL FUNCTIONS. A qualified individual must be able to perform the essential functions of the job as listed, with or without accommodation. (An Asterisk (*) Identifies an Essential Function)

• Meet assigned deadlines for updating Medical Necessity database. (*) Accurately update rules database with revised data and documents from Medicare contractors before assigned deadlines. This may involve having a very flexible schedule to include weekend work or additional hours, if necessary.
  • Read policy on CMS website, identifying coding restrictions in the policy (e.g., covered or non-covered CPT or ICD codes, age restrictions, gender restrictions, or frequency restrictions).
  • Check coding restrictions identified above against what’s in MediQuant’s database. Add/update coding in database as necessary.
  • Escalate any issues to Medical Necessity Supervisor.
• Complete combing assignments. (*) This includes confirming that all policies, articles and documents from a specific contractor are included in our database and reviewing each policy, article and document for accuracy.
  • Compare contractor index on CMS to policies entered in MediQuant’s database to ensure all policies are there.
  • Read policy on CMS website, identifying coding restrictions in the policy (e.g., covered or non-covered CPT or ICD codes, age restrictions, gender restrictions, or frequency restrictions).
  • Check coding restrictions identified above against what’s in MediQuant’s database. Make additions/updates/corrections as necessary.
  • Escalate any issues to Medical Necessity Supervisor.

Competencies

• Critical Thinking
• Professionalism and Composure
• Exceptional Communication Skills
• Flexibility
• Team Player
• Self-Motivated
• Quick Learner
• Strong Communication Skills
• Detail Oriented
• Focus and Diligence

Supervisory Responsibility. Position does not have supervisory responsibilities.

Required Education and Experience.

• High School Diploma or GED required plus three (3) years previous work experience in an analytical, auditing or legal environment
• Proficiency with MS Office, particularly in Excel, Word and Outlook
• Must be able to work independently in a remote work environment with minimal supervision
• Medical necessity data changes quickly, adaptable knowledge is a must.
• Will be responsible for documenting special situations on internal spreadsheets and in Utility.
• Attention to detail – must enter information accurately.

Additional Eligibility Qualifications.

• Must be able to discover and resolve policy revision ambiguity and contradictions.
• Able to flex work hours to complete updates as published outside of standard office hours
• Able to collaborate with other team members to meet deadlines.
• Ability to return to task after interruptions or move to other tasks while waiting on responses
• Able to juggle multiple assignments well and prioritize and execute tasks.

Work Environment. The Rules Specialist position is a remote assignment. Incumbent works from home.

Physical Demands. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Position is primarily stationary with the need to stand or sit 80% of the workday.

Manual dexterity: Constantly operates a computer and other office productivity machinery, such as a keyboard, mouse, and computer printer.

The employee is occasionally required to sit; climb or balance; and stoop, kneel, crouch or crawl.

Position Type/Expected Hours of Work. Flexibility in hours is allowed. Occasional weekend work may be required to meet deadlines.

Travel. No overnight or out of town travel is expected for this position. It is anticipated incumbent will travel to attend department or company meetings.

Work Authorization/Security Clearance (if applicable). In compliance with Federal employment laws, MediQuant will verify the identity and employment authorization of each person hired.

AAP/EEO Statement. MediQuant, LLC, is an equal-opportunity employer.

Other Duties. Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time.