Position Purpose: This position uses knowledge of benefits and contracts to identify benefit exceptions whether internal or external and resolves provider participation to auth.

Primary Responsibilities:

1. Responsible to conduct Medical Policy research and assist in development of medical policies. This includes:
a. Assure all policies are reviewed on an annual basis. Policies that are due for review are identified in advance, compared against national policy, competitors, and recent medical information to assure medical policy is current.
b. Updates policies for review assuring correct formatting, grammar and reference material.
c. Upon approval, publish clinical policies to Power DMS and Web Admin (provider portal).
d. Prepare quarterly policy agenda for QIC/MAC.
2. Researches policy application around new codes published by CMS. Release and review findings and code team and management.
3. Tracks quality assurance and benefit application of third-party authorization vendor, Valenz.
a. Identified benefit and authorization conflict
b. Participation status of providers and auths
4. Performs high dollar member tracking including:
5. Maintains an Exception log, tracking authorized exceptions to benefits or contract.
6. Under guidance of Management, prepares medical management process guidelines and maintain annual review of existing process guidelines.
7. Assist in preparation of monthly department KPI reporting.
8. Assist with requests from Valenz and Premise via Teams channels.
9. Perform departmental authorization system audits (vendor to QNXT data).
10. Serve as back up to Senior Intake Coordinator job duties.
11. Serve as back up to Med Man Claims workflow queue.

Critical Required Skills:

1. Analytical ability necessary to participate in the development of department and operational business plans, policies and procedures, and evaluate department effectiveness.
2. Ability to analyze sources of information, documentation, statements, and contracts.
3. A working knowledge of medical coding (ICD, CPT) and business terminology.
4. Extensive QNXT literacy necessary to access, interpret, and communicate system configurations pertaining to benefits.
5. Ability to access data using information systems required to complete analysis and reporting requirements.
6. Ability to understand PHP custom database layout, format, and information usage.
7. Organizational skills necessary to coordinate and prioritize workload and to maintain tracking systems and related information in readily retrievable formats.
8. Analytical abilities required to manipulate data programs used in generating descriptive reports and in their corresponding analysis.
9. Effective research and problem-solving skills.
10. Detail-oriented.
11. Ability to work in a self-directed environment with minimal direction.

A High School Diploma or equivalent. Three to five (3-5) years of managed health care experience preferred. Strong computer skills and a working knowledge of data management and analysis concept. Experience reviewing benefit contracts and medical terminology a plus.