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Role Description

The Health Plan Data and Medical Policy Clinician analyzes data, as well as coverage, payment, and coding policies, reviews findings, and informs, supports, and makes recommendations to Utilization Management leadership as well as other Clinical Programs at Martin’s Point Healthcare. The Senior Clinical Analyst uses their extensive clinical and coding knowledge and analytical expertise to guide and educate leaders on health plan data clinical optimization from a range of operational lenses and levels of analysis as well as informing system configuration, data feed requirements, and reporting specifications.

This individual develops medical policies for the purpose of Utilization Management and Medical Necessity determinations. This individual will also assist in development and maintenance of Prior Auth List.

Qualifications

• Associates degree in nursing
• BSN preferred
• Current, unrestricted Registered Nurse licensure in Maine
• One or more of the following Certified Professional Coder Certifications (CPC, CCS, CCA, CPMA)
• 5+ years medical management experience in a managed care setting including Quality Management, Case Management, Disease Management, Utilization Management and Population Health
• Experience related to reporting and analysis of health care data ideally in the areas of managed care, health care delivery, code sets, and/or reimbursement
• Experience with ICD10, CPT, HCPCS, and Revenue coding and payment systems for managed care
• Experience with creating medical policies under the Medical Policy Committee
• Experience with Prior Auth list review, addition and deletion of codes driven by evidence and utilization data
• Experience in creating, reconciling, summarizing, and analyzing data with SQL knowledge preferred

Requirements

• Knowledge of health plan system application configuration/functionality and reporting
• Maintains working knowledge of DOD, CMS, NCQA, CCMC, State/Federal regulations, and contractual obligations that affect HMD activities and departmental processes through collaboration with all related health plan departments
• Maintains exemplary knowledge of each health plan line of business and impact(s) to HMD functions
• Maintains exemplary knowledge of coding principles
• Maintains knowledge of payment systems (IPPS, OPPS, PFS, DRG, APC, DMEPOS, …) and impact on reimbursement
• Maintains an understanding of health plan quality standards and measurements
• Maintains knowledge of managed care computer systems, features, reporting, claims system, and claims processing practices including systems used throughout Martin’s Point (e.g., QNXT, Athena, Salesforce, Microsoft Office, iPro, SharePoint, Optum products, Cognos, Tableau, SQL Server Management, etc.)

Skills

• Excellent interpersonal, verbal, and written communication skills including team building, and quality improvement skills

Abilities

• Demonstrates an understanding of and alignment with Martin’s Point Values
• Demonstrated ability to manage, organize and prioritize workload and multiple competing demands in a timely accurate manner and function independently
• Demonstrated knowledge of project management principles including ability to identify root causes and implement creative solutions with strong analytical and problem-solving skills
• Ability to manage complex interdepartmental processes utilizing data to inform decision making and evaluate impacts. Aptitude for matching business requirements to potential software solutions