Job Description

Medical Policy Consultant

National Government Services is a proud member of Elevance Health Companies, Inc. family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

Location : This is a virtual position, and preferred candidates reside within 50 miles of an Elevance Health PulsePoint location.

Shift : Monday - Friday 8 am - 4 : 30 pm EST.

The Medical Policy Consultant is responsible for researching and drafting NGS Medical Policy ensuring the use of valid and consistent research methodologies.

How you will make an Impact :

• Conducts structured research within defined methodologies.
• Drafts and modifies policies using consistent template tools and criteria.
• Review new and updated codes for accuracy and consistency.
• Research relevant studies and review articles for the development of local coverage determinations, coverage articles, and coding guidelines and for responses to inquiries from providers.
• Finalizes issues and ensures implementation of these policies.
• Works with other internal areas and with the Medical Directors to respond to internal and external requests that seek written clarification of a general or specific policy question.

The response may be a reiteration of an established policy a redefinition of the current policy or research to determine a new revised policy.

• Attendance and understanding of edits via the Edit Effectiveness meetings is a critical skill.
• Ability to think on your feet and learn the policy consultant job quickly.
• Scheduling Open Meetings / CACs and informal meeting processes must be learned.
• Review and respond to OIG, CMS questions, and FOIA requests in a timely fashion.
• Must be able to formulate a written policy in collaboration with Medical Directors and attend workgroup meetings and weekly CMD / MPU meetings.

This must be based on significant research using Hayes and other tools available to the policy team.

Minimum Requirements :

• Requires a BA / BS degree in a related field and a minimum of 2 years related experience; or any combination of education and experience which would provide an equivalent background.
• Travels to worksite and other locations as necessary.
• Working knowledge of coding is required.
• This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States at least three of the past five years.

Preferred Skills, Capabilities, and Experiences :

• RN license is preferred.
• Prior medical literature research experience or related experience is preferred.
• Technical writing experience preferred.
• Excellent writing and communication skills and attention to detail as well as a love of research.
• In-depth knowledge of ICD-10, CPT, and HCPCS codes is preferred.
• Understanding edits / audits in FISS and MCS is preferred.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.

Requirements include but are not limited to more stringent and frequent background checks and / or government clearances, segregation of duties principles, role-specific training, monitoring of daily job functions, and sensitive data handling instructions.

Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

The use of this job is limited to the Federal Government Services business unit.

Job Level :

Non-Management Exempt

Workshift :

1st Shift (United States of America)

Job Family : MED >

MED >

Medical Policy

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health.

Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates.

Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week.

Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient / member-facing roles to become vaccinated against COVID-19.

If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Last updated : 2024-05-22