[Hiring] Manager Medical Affairs @American Recruiting & Consulting Group

Role Description

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 Medical Directors regarding clinical/medical decision making for the organization.

Essential Responsibilities

• Leads the Medical Policy Team and manages the following functions: (85%)
• In conjunction with the Medical Directors, 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, ensuring inclusive membership and scheduling/facilitating all required meetings.
• Responsible for oversight of scheduling/facilitating all Open meetings required by CMS.
• Responsible for receiving, assigning, tracking, and ensuring the timely completion of all Medical Director, medical policy, pricing, coding, and clinical inquiries.
• Responsible for oversight of contractor pricing to create local fees for procedure codes and services not priced by CMS.
• Provides daily supervision to team members, ensuring commitments are met in a timely, accurate, and efficient manner.
• Provides ongoing and timely communication to the team and operational areas.
• Ensures professionalism and proper conduct of the team and provides necessary training/guidance.
• Facilitates department actions to meet or exceed all performance expectations.
• 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.
• Collaborates with other department managers/leaders regarding work hand-off and related communication.
• Responsible for accurate and timely submission of various required CMS reports.
• Supports the development and maintenance of databases as needed to support team functions.
• Communicates with CMS on items such as proposed and final Local Coverage Determination policies.

Qualifications

• Bachelor's degree with five (5) years' related work Medicare experience, including 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 focused 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.
• Professional demeanor and positive approach to work.
• Excellent planning, organizing, time and work management skills.

Requirements

• Active and current Registered Nurse (RN) license.

Preferred Qualifications

• Bachelor of Science Degree in Nursing (BSN).
• Certified Professional Coder (CPC) credential.

Benefits

• Competitive salary and bonus.
• Generous benefits package.