Medical Policy Admin Coord

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

Committees and Workgroup Management:

• Manage the review and update of committee charters in collaboration with leadership. Monitor committee compliance with charters and procedures. Work with the chairperson to address gaps.

• Oversee data integrity in committee databases and document repositories.

• Organize and file committee meetings materials, per regulatory and Horizon Guidelines for audit readiness. Develop and maintain detailed documentation on committee processes, workflow, and procedure for the medical policy end to end process playbook.

• Schedule meetings, create, manage, and submit agenda including meeting material prior to the meeting, track follow-up items, and upload documents to SharePoint.

• Take detailed meeting minutes, with complex medical and technical information, at meetings, distribute them, maintain issue log, and ensure follow-up on action items and issues until completion or resolution.

• Create meeting presentations that include clinical, coding and integration content and incorporate input from multiple sources. Ensure timeliness and flawless execution.

• Highlighted bullets are part of current description.

• Train new committee and workgroup members on policies, procedures, and charters and Coordinate scheduling of committee members.

Medical Policy and HPIRT department coordination and Support:

• Manage multiple priorities and interface with senior leaders within Horizon regarding the team's priorities. Interface outside of horizon coordinating peer to peer discussions as well as reviews of the appeals processes. Proactively resolve gaps in workflows, deliverables and inquiries and keep stakeholders informed.

• Provide general administrative support reviewing and responding to incoming and outgoing correspondence regarding specific Medicaid inquiries such as continuation of enrollment reviews.

• Coordinate communication and material submission with multiple Independent Medical Expert (IME) vendors (MES, MCMC).

• Coordinate new employees on-boarding including education sessions, monitoring HR requirement, coordinating equipment and access to relevant applications. In addition, oversees use of hardware, office supplies and applications access to the department employees.

• Manage ACM access to the EMM (evidence management Module) based on security permissions.

• Manage departmental contingent workers recruitment, maintenance facing sourcing and invoice management and payments. Manage departmental administrative budget and expense accounts including invoices for multiple vendors and maintenance of organizational memberships. Manages and provides Forecasts for departmental assigned cost centers.

• Prepare presentations and FAQ's supporting documentation internal/external audits.

• Coordinate and monitor the medical director's transactional volume for appeals, appeals committees, and escalations.

• Coordinate medical directors' quality week including assignments to member appeals committees and internal peer reviews.

• Analyze data, identify trends and compile reports. Run recurrent and ad Hoc SAS reports to provide utilization data for specific medical policies. Prepare reports based on committee findings. Manage Tableau dashboard updates to support the utilization analysis for medical policy development, maintenance, and executive summaries.

• Perform other duties as needed.

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Minimum of five (5) years of work experience in the healthcare industry.

• Proficiency in using personal computers, Microsoft Office Suite (Word, Excel, PowerPoint) and of intranet/internet applications such Outlook, SharePoint, Webex.

• 3-4 years experienced in healthcare setting.

• General knowledge and/or familiarity with medical terminology (preferred).

• Demonstrated ability to identify and resolve problems independently.

• Strong prioritization, time management, organizational, and teamwork abilities and skills.

• strong verbal and written communication skills.

• Detail-oriented with proven ability to take initiative, follow instructions, and solve problems.

• Adaptability and ability to manage multiple responsibilities.

• Ability to have positive working relationships with all levels of professionals (internal & external).

• Ability to build relationship with outside customers- providers and members.

• Ability to analyze and organize data for reports.

• Effective presentation skills and ability to answer questions from groups (preferred).

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.