[Hiring] Medical Policy & Coding Project Consultant @Capital Blue Cross

Role Description

The MPC Project Consultant is responsible for leading and supporting cross-functional initiatives related to Medical Policy and Coding (MPC). This role applies advanced knowledge of clinical care, evidence-based practice, coding, claims administration, healthcare data analysis, IT&D, and operational workflows to support the development, evaluation, and implementation of organizational initiatives. The consultant supports Capital’s mission by researching and developing clinical services that align with evidence-based practice and benefit coverage requirements. The role serves as a clinical, business, and technical resource to MPC Clinical and Coding Coordinators and collaborates with stakeholders across the organization to drive effective decision-making and process improvements.

• Thoroughly research, maintain, and identify CPT, CDT, HCPCS, ICD-10 and revenue codes to meet business needs.
• Independently manage episodic/special projects, including in-depth clinical and business research, collaboration with other departments, and development of sound, evidence-based policy/clinical recommendations.
• Independently draft and/or revise medical policies classified as Large or X-Large related to projects and other policies, as assigned.
• Independently prepares recommendations for internal audits, client audits and/or insurance department audits, for MPC leadership and the Capital Legal Team.
• Attends external BCBSA MPP Monthly meetings, conducts in-depth clinical research for scientific evidence, and proposes medical policy adoption to MPC Leadership.
• Conducts independent interdepartmental networking in support of clinical initiatives involving medical policy and coding activity.
• Independently completes new code Phase II clinical review of quarterly and annual codes. Assists with clinical review of annual ICD-10 code adoption/review.
• Work collaboratively with the Coding Team Lead to provide training to staff.
• Perform other related duties as assigned.

Qualifications

• Ability to interact with a high level of professionalism with all levels of internal/external personnel.
• Demonstrated analytical skills.
• Able to gain knowledge of new clinical and business processes and issues quickly.
• Advanced problem-solving and structured analysis/design techniques.
• Ability to adapt to constantly changing priorities.
• Project management ability and use of project plans.
• Ability to communicate effectively in written and verbal form.
• Ability to work independently, schedule and manage time effectively.
• Ability to adjust to changing job requirements and priorities.

Requirements

• Knowledge of the health care industry, including standards, policies, and procedures for multiple departments/systems.
• Knowledge of technological applications, terminology, and concepts.
• Strong working knowledge of benefits, payment policies, and claims operating systems.
• Strong working knowledge of Government regulatory and accrediting requirements.
• Advanced understanding of medical terminology.
• Basic knowledge of current and emerging treatment modalities.
• Knowledge of IT&D, pre-configuration and configuration processes.
• Proficiency in analyzing data and presenting it effectively.
• Proficiency in data analysis/trending through analyzing claims data related to medical coding.

Experience

• Minimum of 5 years in a clinical setting, and medical coding position, preferably in a managed care/health insurance related position.
• Preferred five (5) years’ experience of medical coding including ICD-10, CPT, CDT, HCPCS and revenue codes.

Education and Certifications

• Current, non-restricted clinical license.
• Bachelor’s Degree in Nursing, required.
• Advanced Practice Provider degree, preferred.
• Certification from the American Association of Professional Coders (AAPC) Medical Coding.

Work Environment

• Work at home, office.

Physical Demands

• Frequently required to sit, use hands and fingers, talk, hear, and see.
• Occasionally lift and/or move up to 5 pounds.

Company Description

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital, you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.