[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.

Responsibilities

• 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
  • Development of sound, evidence-based policy/clinical recommendations both internally and externally
• Independently draft and/or revise medical policies classified as Large or X-Large (often complex) 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 data 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.

Benefits

• Comprehensive benefits package including Medical, Dental & Vision coverage.
• Retirement Plan.
• Generous time off including Paid Time Off, Holidays, and Volunteer time off.
• Incentive Plan.
• Tuition Reimbursement.