Medical Policy Analyst

_MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people._
• Medical Policy Analyst
• Location:
• This position will work on-site on Torre Chardon Building, Chardon Ave. 350 Suite 500 San Juan, Puerto Rico.
• Schedule:
• This position will work a 1st Shift from 8:00 am- 5:00 pm Monday thru Friday. Additional hours or days may be required based on operational needs.
The
• is responsible for medical research and developing criteria for medical policies to be used by review, utilization, and case management nurses.
• How you will make an impact
• Primary duties may include, but are not limited to:
• Review existing policies on a quarterly basis to ensure policy is update accordingly with latest version of the regulatory agency or other source as mentioned above.
• Actively collaborates in the evaluation of new incoming CMS medical policies (NCD, LCD, Medicare manual and or Articles changes).
• Support the clinical operations in the regulatory process; make all guidelines public. These include but is not limited to removal, replacement and or a new publication of policies.
• Researches and evaluates medical claim issues against local and national Medicare policy guidelines.
• Reviews new and updated codes for accuracy and consistency.
• Researches relevant studies and reviews articles for development of local medical review policies and for responses to inquiries from providers.
• Works with Medical Directors on development of local medical review policies.
• Assists operations by reviewing complex and non-standard type of claims as related to a policy.
• Codes changes into clinical systems using national coding structure for processing accuracy and clinical appropriateness once medical policy has been established by physician plan committee.
• Serves as a liaison to business units for correct coding of clinical codes.
• Researches questions and issues from internal physicians and nurses as they relate to developed medical policies.
• Responds to internal and external requests that seek written clarification of a general or specific policy question.
• The response may be reiteration of an established policy, a redefinition of the current policy, or research to determine a new or revised policy.
• Minimum Requirements:
• + Requires a BA/BS degree and a minimum of 2 years related experience including clinical experience and may include operations experience; or any combination of education and experience which would provide an equivalent background.
• Typically requires active state RN license.
• Preferred Skills, Capabilities, and Experiences:
• + Bachelor's degree in a clinical healthcare discipline or nursing degree preferred.
• Clinical licensure (PR registered nursing license) preferred.
• Travels to worksite and other locations as necessary.
• Fully Bilingual (English & Spanish). Must be able to write, read and speak both languages in a proficiency level.