Job Summary:

The Medical/Clinical & Reimbursement Policy Writer researches and develops moderate to complex medical, administrative and reimbursement provider policies; ensures adherence to company, state, and federal guidelines.

Essential Functions:

• Support the operational processes of the Clinical Provider Policy Governance Committee (CPGC)
• Ensure all new and existing configuration rules are incorporated into the clinical policies
• Responsible for the tactical activities related to the support of CareSource’s reimbursement policies
• Provide medical, administrative and reimbursement policies policy deliverables for all lines of business
• Participate in department initiatives and projects
• Ensure all reimbursement policies are compliant with relevant regulations and are consistent across all lines of business (duplicate with clinical policy writer)
• Assist, Identify and define Claims Ops solutions to meet regulatory requirements
• Coordinate with subject matter experts to develop policy on issues that impact CareSource from medical/clinical, and reimbursement policies policy perspectives
• Support cross functional teams with responses and restitution projects
• Remediate gaps in existing processes related to medical, administrative and reimbursement provider policies that do not meet regulatory requirements
• Work with business product owners, government relations, and compliance leads to monitor legislative and regulatory activities for potential impact on existing or proposed policies
• Collaborate with interdisciplinary team members to achieve team goals
• Monitor status reports to ensure effective workflow and timely development of medical, behavioral health, administrative and reimbursement policies
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s Degree or equivalent years of relevant work experience is required
• Technical writing experience is required, preferably healthcare policy or related
• Previous managed care experience to include experience with medical coding, claims payment, and/or retrospective claims reviews is preferred
• Healthcare experience strongly preferred

Competencies, Knowledge and Skills:

• Ability to develop detailed data specifications
• Knowledge of Clinical Editing applications
• Understanding of Healthcare Economics
• Knowledge of NCQA policy timely requirements
• Strong understanding of healthcare reimbursement practices
• Ability to translate ideas into clear and concise written communication
• Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
• Knowledge of medical terminology and claims payment policies
• Advanced analytical skills, with the ability to interpret and synthesize complex healthcare literature
• Ability to interpret complex clinical information and apply to policy development
• Excellent verbal and written communications skills
• Strong presentation and decision-making skills
• Excellent organization and tracking skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to handle multiple priorities/projects simultaneously

Licensure and Certification:

• RN or equivalent clinical licensure preferred, or in lieu of licensure: 2 years Clinical /Medical policy writing experience or equivalent Policy/Healthcare experience
• CPC, CCS, COC, CIC Preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Virtual office opportunity, with occasional travel to main office

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.