SUMMARY STATEMENT
This position is responsible for managing/directing the medical affairs team including Research Analysts, Pricing Consultants, Policy Nurses, Business Analysts, Medical Research Consultants, and other specialized personnel in project endeavors related to the development, implementation, operationalizing, and communication/education of local coverage determinations and local contractor pricing. The position is also accountable for handling complex medical policy inquiries and collaborating and supporting the Contractor Medical Directors (CMDs) regarding clinical/medical decision making for both First Coast and Novitas. These functions are detailed in the section below.

 

ESSENTIAL RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Leads the First Coast/Novitas Medical Policy Team and manages the following functions: (85%)
* In conjunction with the CMDs, responsible for all Local Coverage Determinations (LCD) activities which include LCD clinical evidence research to determine validity of evidence, LCD development, internal/external LCD communication and education, LCD analysis for revision or retirement, creation of coverage and billing coding articles relating to LCDs, LCD effectiveness and LCD reconsideration requests.
* Responsible for the timely establishment and implementation of effective LCD edits in the Multi-Carrier System (MCS) and Fiscal Intermediary Shared System (FISS) to operationalize all LCDs to ensure the accurate processing of claims. Ensures education is provided on the LCD and LCD edits to all operational areas (i.e., Claims, Appeals, Medical Review, Prior Authorization, Informatics, etc.).
* Responsible for oversight of stakeholder engagement and transparency regarding LCD and local pricing activities.
* Responsible for the Contractor Advisory Committee, a group of external healthcare professionals who are informed of the evidence used in developing LCDs and who promote communications between First Coast and Novitas and the healthcare community, to include ensuring inclusive membership and scheduling/facilitating all required meetings.
* Responsible for the oversight of scheduling/facilitating all Open meetings which are required by CMS to allow interested external parties the opportunity to make presentations of information and offer comments related to new proposed LCDs.
* Responsible for receiving, assigning, tracking, and ensuring the timely completion of all CMD, medical policy, pricing, coding, and clinical inquiries from operations, stakeholders, CMS, law enforcement, other CMS contractors, etc.
* Responsible for receiving, assigning, tracking, and ensuring the timely completion of all CMD Assistance requests from all operational areas to resolve outstanding clinical issues/questions.
* Responsible for the oversight of contractor pricing to create local fees for procedure codes and services not priced by CMS and ensuring the fees are readily available to all operational areas (i.e., Claim, Appeals, Medical Review (MR), Prior Authorization, Informatics, etc.).
* Provides daily supervision to team members, including oversight of workload, tracking progress and status of activities and projects, and ensuring that commitments are met in a timely, accurate, and efficient manner in compliance with all Centers for Medicare & Medicaid Services (CMS) rules and regulations.
* Provides ongoing and timely communication to the team and operational areas.
* Ensures the professionalism and proper conduct of the team and provides technical, clinical, and professional training/guidance as necessary.
* Facilitates department actions to meet or exceed all performance expectations in a compliant manner.
* Ensures appropriate procedures are in place to meet the department's objectives. Assists in the on-going evaluation of the effectiveness of existing processes and procedures.
* Participates in various workgroups or projects aimed at analyzing identified issues and recommending/implementing corrective action.

Controls, Quality and Continuous Improvement: (15%)
* Leads the ongoing evaluation and monitoring of the controls and quality systems within the Policy department. Monitors individual and departmental quality and leads the team in root cause analysis and corrective action regarding any non-conformances. Leads the team to take appropriate action to reduce or eliminate errors.
* Collaborates with other department managers/leaders regarding work hand-off and related communication, process improvements, efficiencies, and issues as needed. Develops, recommends, and implements solutions to department issues identified either internally or externally.
* Responsible for accurate and timely submission of various required CMS reports.
* Supports the development and maintenance of databases as needed to support team functions, ensures timeliness and accuracy, maintains and improves communication and facilitates required reporting.
* On behalf of the department, communicates with CMS on items such as proposed and final Local Coverage Determination policies, claims processing edits, contractor pricing and methodology for contractor pricing, Congressional offices, law enforcement agencies, stakeholders and attorneys, providers and representatives of hospitals and health systems.

Performs other duties as the supervisor may, from time to time, deem necessary.

 

 

REQUIRED QUALIFICATIONS
* Bachelor's degree with five (5) years' related work Medicare experience. This includes 4 years' direct supervisory/project management lead or other leadership experience.
* Effective oral, interpersonal, and written communication skills; ability to communicate with confidence with other medical professionals, including physicians.
* Excellent analytical, problem solving and decision-making skills.
* Knowledge of Medicare policies and procedures, current claims processing systems.
* An understanding of medical issues to effectively manage a department whose activities focus on medical issues.
* Comprehensive knowledge of programs administered by Medicare.
* An understanding of local coverage, contract, pricing, and claims processing issues.
* Comprehensive knowledge of medical, surgical and diagnostic procedures and terminology.
* Ability to communicate with confidence with other medical professionals, Medical Societies, Medicare providers, CMS and Contractor Advisory Committee (CAC) members.
* Professional demeanor and positive approach to work.
* Excellent planning, organizing, time and work management skills.

CERTIFICATIONS, LICENSES, REGISTRATIONS
* Active and current Registered Nurse (RN) license

 

 

PREFERRED QUALIFICATIONS
* Bachelor of Science Degree in Nursing (BSN)
* Certified Professional Coder (CPC) credential