Medical Policy Clinical Specialist

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience.  Some of our offerings include:

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

• Annual incentive bonus plan based on company achievement of goals

• Time away from work including paid holidays, paid time off and volunteer time off

• Professional development courses, mentorship opportunities, and tuition reimbursement program

• Paid parental leave and adoption leave with adoption financial assistance

• Employee discount program

Job Description Summary:

The Medical Policy Nurse Specialist researches, coordinates, analyzes, and provides clinical expertise in the application of medical policy and clinical UM guidelines ensuring the use of valid and consistent research methodologies. Follows company guidelines and acts as a clinical subject matter expert resource for medical policy to internal customers. Able to perform duties with limited supervision. The candidate for this position must reside in the Kansas City metropolitan area.

Job Description

• Conducts structured research of peer-reviewed literature and other resources within defined methodologies using consistent templates, tools and criteria to support

• Completes maintenance of existing policies, medical policy updates and modifications through information presented from BCBSA, MCG, Avalon, and other external UM vendors

• Possesses knowledge of MCG criteria and familiarity with MCG Guideline Modification Module and Cite AutoAuth to maintain up to date medical policy criteria for UM

• Evaluates and assesses potential new topics for development into Blue KC’s medical policy database

• Plays an active role in preparing medical policy updates for medical policy committee and considering impacts to clinical editing system to recommend necessary updates

• Reviews new and updated codes for appropriate application within the policy and guideline framework

• Works with key stakeholders across the business to understand financial impacts and need for new medical policy based on new evolving medical technology

• Collaborates across enterprise-wide workgroups and business units to facilitate proper implementation of medical policy and clinical UM guideline changes

• Responds to internal and external inquiries that warrant written clarification of a general or specific question regarding medical policy

Minimum Qualifications

• Associate or Bachelor’s degree in Nursing

• Licensed RN in Missouri and/or Kansas

• 3 years of clinical experience

• Experience reading and understanding clinical literature

• Certified Coder with AHIMA or AAPC, or willing to obtain within 6 months of employment

• Advanced beginner to intermediate skills in PowerBi and reporting.

• Must be task oriented and able to meet designated deadlines, productivity standards and able to work independently

• Ability to effectively present information in one-on -one or small group situations to customers, clients and other employees of the organization

• Ability to define problems, collect data, establish facts and draw valid conclusions

• Intermediate level knowledge of Microsoft Office, Word, Excel

Preferred Qualifications

• Nursing degree, MPH, or equivalent

• 5 years of related experience in research, Utilization Management, and medical policy work

• Strong understanding of Blue KC core systems (including facets, Claims Xten

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.