It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

In collaboration with the Medical Directors and the Office of Clinical Affairs, the Medical Policy Manager is responsible for the overall development, coordination and management of the Plan's medical policies and clinical review criteria for behavioral health services. This includes developing corporate medical policies/clinical review criteria and coordinating the Plan’s medical technology assessment process in accordance with state, federal and accrediting organization requirements, including NCQA, and managing the medical policy/clinical review criteria development and revision function from research stage to writing to committee(s) approval to external communication.

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Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits

Key Functions/Responsibilities:

· Thoroughly researches objective scientific evidence and professional guidelines for applicable services. Partners with the Director, clinical team, and subject matter experts (SME’s) to evaluate, update, and operationalize clinical review criteria for behavioral health services. Clearly documents clinical decisions (and clinical rationales) during the medical policy review process for established clinical review criteria and new/proposed clinical review criteria, as well as benchmarking other payor guidelines.

· Reviews, updates, and documents revisions to all components of established medical policies from initial draft to final edits for review and approval by the Utilization Management Committee (UMC) according to NCQA guidelines and applicable regulatory and contractual requirements.

· Develops new clinical coverage criteria policies from initial draft to final edits for review and approval by the UMC according to NCQA guidelines and applicable regulatory and contractual requirements.

· Engages practice specialists in the medical policy review process to gather expert opinions (e.g., meetings and/or correspondence with BMC physicians and other network providers, submitting policies for AMR physician review, and requesting Hayes ad hoc reports). **** Maintains external specialist list for review of clinical policies. Coordinates all external policy reviews and presents final recommendations to UMC.

· Performs a detailed and timely clinical and code review of quarterly code loads for industry-wide CPT, HCPCS, and ICD-10 code updates in collaboratively with the Medical Policy Program Analyst within an aggressive timeline.

· Researches clinical inquiries and/or questions related to medical policies; documents issues and final resolution on Medical Policy tracking forms.

· Provides support in Medical Policy presentations and assists with internal and external meetings that involve the Medical Policy team.

· Coordinates the request for data analyses for new and annual review of clinical coverage criteria policies and ad hoc inquiries.

· Responsible for annual reviews and updates to clinical coverage criteria according to the medical policy review calendar.

· Assists with the development of the annual inter-rater reliability tool for clinical staff and Plan medical directors that are applicable to clinical coverage criteria.

· Performs appropriate research for the Plan’s Medical Directors to support clinical decisions for individual case determinations, as necessary.

· Provides clinical input and support to the member grievance and appeal process, as necessary.

· Serves as a resource for internal staff on clinical questions related to medical policy guidelines for behavioral health services.

· Assists the Director and Senior Medical Director of Medical Policy in strategic development and expansion of medical policies to meet the Plan’s business objectives.

· Supports and customizes medical policies/clinical review criteria into the InterQual Platform and provides ongoing maintenance to the policies/clinical review criteria.

· Other duties, as assigned.

Supervision Received:

• General supervision is received weekly

Qualifications:

__Education:

• Bachelor’s degree in nursing or the equivalent combination of education training and experience

Preferred/Desirable:

• Master’s degree in nursing, health services, or public health

Experience:

• 6 years of experience in managed care setting, including utilization management
• Knowledge of coding essential, Certified Professional Coder (CPC) preferred

Preferred/Desirable:

• 5+ years of clinical experience in behavioral health services
• Prior experience with medical policy development
• Working knowledge of Medicare (including NCDs and LCDs) and Medicaid guidelines
• Experience and thorough working knowledge of InterQual and MS Office

Required Licensure, Certification or Conditions of Employment:

• Registered nurse with current active license preferred. Will consider other licensed allied health care professionals with comprehensive medical policy experience
• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Excellent oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts
• Demonstrated strong organization and time management skills
• Able to work in a fast-paced environment; ability to multi-task and work independently
• Strong working knowledge of Microsoft Office products
• Detail oriented, excellent proofreading and editing skills
• Ability to maintain high-quality service by establishing and enforcing organizational standards

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position
• Work is normally performed in a typical interior/office work environment
• No, or very limited physical effort required, no, or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Required Skills

Required Experience