Medical Policy & Coding Project Consultant – RN/CRNP

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Lead and support cross-functional projects related to Medical Policy and Coding.

• Utilize knowledge of clinical care, evidence-based practices, coding, claims administration, healthcare data analysis, IT&D, and operational workflows to advance organizational initiatives.

• Research and develop clinical services that align with evidence-based practices and benefit coverage requirements.

• Act as a clinical, business, and technical resource for MPC Clinical and Coding Coordinators.

• Conduct research, maintain, and identify relevant CPT, CDT, HCPCS, ICD-10, and revenue codes.

• Independently oversee episodic and special projects.

• Perform clinical and business research to formulate evidence-based policy and clinical recommendations.

• Draft and revise intricate medical policies.

• Prepare recommendations for internal, client, and insurance department audits.

• Attend external BCBSA MPP monthly meetings and advocate for the adoption of medical policies.

• Engage in interdepartmental networking to support clinical initiatives.

• Complete new code Phase II clinical reviews and assist with the annual ICD-10 code review.

• Collaborate with the Coding Team Lead to deliver staff training.

⛳️ Requirements

• At least 5 years of experience in a clinical setting and a medical coding role.

• Preferably possess experience in managed care or health insurance.

• A minimum of five years of medical coding experience, including ICD-10, CPT, CDT, HCPCS, and revenue codes is preferred.

• Current, unrestricted clinical license is required.

• Bachelor’s Degree in Nursing is mandatory.

• AAPC Medical Coding certification is required; employees without certification may take the offered course.

• Continuing education credits must be completed to maintain AAPC certification.

• Exhibit professionalism while interacting with both internal and external stakeholders.

• Capability to prepare written documentation and deliver oral presentations for both clinical and non-technical audiences.

• Skills in meeting leadership and project management.

• Proven analytical skills are essential.

• Advanced problem-solving abilities and structured analysis/design techniques are required.

• Ability to work autonomously with minimal oversight.

• Proficiency in project management and utilization of project plans.

• Capacity to manage confidential information in compliance with HIPAA and other regulatory expectations.

• Familiarity with healthcare industry standards, policies, clinical and business practices, claims administration, provider networks, clinical operations, and SIU.

• Knowledge of web-based technologies, SharePoint, SAS, Microsoft Access, Microsoft Excel, reporting and testing software, and the Microsoft Office Suite.

• Strong understanding of benefits, payment policies, claims operating systems, payment processes, and claims adjudication.

• Awareness of government regulatory and accrediting requirements including PPACA, FEP, MS, Pennsylvania regulations, NCQA, URAC, OH, and Medical Assistance.

• Advanced comprehension of medical terminology is crucial.

• Basic understanding of treatment modalities and the interrelationships between medical policy and benefit coverage.

• Familiarity with IT&D, pre-configuration, configuration, and medical policy circulation processes.

• Proficient in data analysis, data presentation, and claims-data trending through medical coding analysis.

🏝️ Benefits

• Medical, Dental & Vision coverage.

• Retirement Plan.

• Paid Time Off.

• Holidays.

• Volunteer time off.

• Incentive Plan.

• Tuition Reimbursement.

• Flexible environment.

• Training and continuing education opportunities.

• Chance to volunteer in the community.