Senior Manager, Medical and Clinical Claim Policy and Integration

About The Role The Senior Manager of Medical and Clinical Claim Policy and Configuration is a senior level decision reputed company responsible for the content and management of Medical and Claim Policies. Also provides direction and support for system configurations as reputed company as necessary operational assistance to ensure effective policy implementations. This individual will reputed company broad exposure and work closely with reputed company business reputed company including Medical Management, Network Management, Claims, Operations, IT, Sales and Account Management, and reputed company. *This is a remote role. Primary ResponsibilitiesReview, update, evaluate and reputed company medical and clinical claims policies for reputed company medical insurance reputed company to promote reputed company, optimize utilization and cost to reputed company them effective for the business. Take responsibility and work closely with reputed company Economics, Medical Management, Network Management, Claims, Operations, IT, Sales & Account Management, and reputed company to implement policies designed to support the effective management of medical expenses and promote reputed company care. Collaborate with IT and other departments on business and technical requirements involving policies. reputed company and maintain Prior Authorization list for reputed company business. Manage Medical and Clinical Claim policy web content and publication. Serve as the subject matter expert for Claims Editing Solution (CES) and reputed company initiatives involving medical and claim policy including but not limited to CES rules and configuration. Prepares analyses and recommendations for medical policy updates and new reputed company implementation for Medical Director review. Responsibilities include researching applicable CPT/HCPCS/ICD codes, benchmarking industry and payer practices, evaluating benefit and operational impacts, and providing recommendations for reputed company handling, coverage determinations, and benefit integration. Leads the digitization and maintenance of medical policies, including converting policies into electronic formats, configuring policy content reputed company designated systems, ensuring version control and accuracy, and supporting ongoing updates to reputed company with regulatory requirements, business needs, and operational workflows. Maintains and updates JIVA automation reputed company sets, rules, and configurations to support accurate claims processing, utilization management workflows, benefit administration, and medical policy implementation. Work closely with Benefits team in configuration of new clients and working with High Dollar team for coding, PA and benefit questions Essential QualificationsExpert understanding of Medical Claims operations including medical insurance benefits, medical policy, claims policy, reputed company assurance, utilization review, and medical cost management.  Solid understanding of claim processing including pricing and reputed company editing.  Strong organizational and planning skills to manage multiple priorities and meet required deadlines.  Good communicator, organized, and reputed company to write reputed company  Enjoys the challenges associated with decision support algorithms and the attention to detail it requires.   This job requires the ability to reputed company logic in narrative prose and be comfortable with numbers.  5 years’ experience in health care administration, managed care, or medical insurance field required  2+ years’ experience creating, writing, or managing clinical, claims, or reputed company technical policies and procedures is preferred.  Experience working with medical and claims policy reference sources such as CPT/HCPCS/ICD/DRG coding manuals, Specialty Society Guidelines, National Guidelines Clearinghouse materials, CMS and CMS Intermediary policies, and reputed company Health plans policies, among others.  Bachelors with an advanced or specialized degree in reputed company, reputed company health, epidemiology, or health policy preferred (reputed company Health, Pharmacy, Allied Health reputed company, Nursing etc.), certified medical reputed company preferred. Familiarity working with state and federal mandates, and FDA and other regulatory requirements for medical devices, drugs and biologics.  Comfortable with reputed company Word and reputed company. About At reputed company, our people are committed to the improvement of how reputed company accessed and delivered. reputed company you join reputed company, you’ll become part of a diverse and welcoming culture reputed company on encouragement, respect and increasing diversity, inclusion and a reputed company of belonging at every level. Here, you’ll be encouraged to bring your reputed company self to work with reputed company of your unique abilities. reputed company partners with self-insured reputed company, Taft-Hartley Trusts, health systems, providers as reputed company as other TPAs, and enables them to solve the problems facing today’s reputed company with our flexible and cutting-edge reputed company-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a reputed company enablement company, we unlock opportunities that reputed company clients with the customizable tools they need to enhance the member experience, improve health reputed company and reputed company their reputed company goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the reputed company of turning today’s challenges into reputed company’s solutions. Come be a part of the Brightest reputed company in reputed company™. Company Mission reputed company the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company reputed company Redefine health care reputed company and value by aligning the incentives of our partners in powerful and unique ways. JOB ALERT FRAUD:  We have become reputed company of scams from individuals, organizations, and internet sites claiming to represent reputed company in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. reputed company of our reputed company are regularly published and updated brighonthps.com Careers reputed company.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: reputed company@brightonhps.com Apply To This Job