Medical Policy Ld

_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 Ld
• 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 oversight of support functions of the corporate medical policy unit.
• How you will make an impact
• Primary duties may include, but are not limited to:
• Evaluates and develops clinical policies according to CMS rules and regulations.
• Responds and guides medical staff and other stakeholders' questions and communicates details about policy and clinical guidelines.
• Monitors day-to-day activities, including work flow, scheduling and PTO.
• Researches and develops new and revised medical policies to ensure that they are in compliance with member contracts, accreditation, and legislation, reflects appropriate medical practice; and are produced and reviewed in a timely manner.
• Ensures all coding associated with medical policy is implemented correctly and in a timely manner.
• Oversees the development and training of coding grids for new and revised medical policies.
• Responsible for yearly CMS Final Rule interpretation, divulgation, and corporate trainings
• Serves as a backup to the medical policy director on various projects relating to medical policy as well as prepare and participate on the medical policy committee.
• Minimum Requirements:
• + Requires a BA/BS in a related field; 5 years of experience in medical policy; or any combination of education and experience, which would provide an equivalent background.
• Preferred Skills, Capabilities, and Experiences:
• + BSN preferred.
• Clinical licensure (PR registered nursing license) preferred.
• 2 years of experience in a supervisory or leadership role preferred.
• Knowledge of ICD-9 and HCPCS coding helpful.
• 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.