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Job Details

Medical Policy Clinical Specialist

Requisition #: 205503
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Allied Health/Clinical Professional
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Dec. 13, 2019

The Medical Policy Clincal Specialist reports to the manager of Medical Policy. The individual conducts clinical, regulatory and industry standard research for the development of JHHC medical policies. With guidance from the Medical Policy Medical Director, the individual drafts policies based on research of evidence for procedure/treatment/device under consideration for policy development. The individual collaborates with the Medical Policy team and assists in monitoring the medical policy cycle timelines from policy creation to implementation. Responsibilites include:

  • Collaborate with coding specialists to provide objective analysis of JHHC coverage and preauthorization requirements with medical policy revisions to ensure consistency of philosophy.
  • Present drafted written policies for consideration by the Medical Director and Medical Policy Advisory Committee (MPAC).
  • Conduct clinical, regulatory and industry standard research for coverage and pre-authorization determinations for quarterly new Healthcare Common Procedural Coding System code updates (HCPCS/CPT) and ad hoc projects from internal and external departments as assigned.
  • Annually review new ICD.10 codes for inclusion on the JHHC sudden and serious diagnosis list in collaboration with the ED Medical Director.
  • Collaborate with internal departments for timely creation of provider notifications related to medical policy work.
  • Assist in upkeep of referral authorization guidelines.
  • Assist in presentations to clinical and non-clinical staff regarding new medical policies and updates of current policies.
  • Act as a clinical resource to coding specialists on the team to ensure timely execution of duties.
  • Compile research and initiate technology assessments and participate in the review of new technology from outside vendors and technology companies.
  • Collaborate in the ongoing quality assurance and improvement of all aspects of medical policy manuals, programs and functions.

Requirements:

Education:

  • Bachelor's Degree in Nursing required. RN with equivalent work experience may be substituted as appropriate.

Knowledge and Skills:

  • Knowledge of managed care principles, policy research and development, business writing and research required.
  • Knowledge of CPT, HCPCS, and ICD 10.
  • Apply clinical nursing knowledge and experience in the review of medical/surgical procedures, technologies and other healthcare services.
  • Medical scientific research and analysis skills; statistical aptitude.
  • Computer skills to work with a variety of databases, excel, and word programs, including internet research and use of specialized software for policy writing and formatting.
  • Ability to work both independently and as a member of the JHHC team. Must possess planning and organizational skills.
  • Exhibits professional verbal, written and listening communication skills. Ability to be detail-oriented and well organized.
  • Work requires interpersonal skills and the ability to maintain a credible and professional image with staff, members, physicians and business-related individuals.
  • Presentation skills for large and small groups.

Work Experience:

  • Minimum of 5 years clinical nursing experience required.
  • Technical, policy, procedure writing research experience required; medical policy writing preferred.
  • Healthcare payer and/or managed care experience is a plus.

PAY GRADE: CM

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.

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