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Medical Policy Coordinator -Carelon


  • National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint



Worksite Strategy : Flex 1, 0-3 days in office per month.

Reporting to the Clinical Manager, Service Delivery, Policy & Training, the Medical Policy Coordinator is responsible for surveillance, analysis, and implementation of government clinical policies and clinical rules, as well as updates and maintenance of clinical tools that support clinical operations in the review of prior authorization requests for both commercial and government lines of business. Responsible for developing and maintaining a systematic process for responding to Corporate Medical Policy inquiries.

Primary duties may include, but are not limited to:

  • Researches and responds to inquiries.
  • Tracks and logs Central Inquiry programs.
  • Maintains electronic communications tools.
  • Analyzes inquiry pattern for improvement opportunities.
  • Investigates new technologies; and serves as a backup to the Medical Policy Research Specialist.
  • Identifies and analyzes federal and state clinical policies, mandates, and coverage determinations (LCDs/NCDs), in partnership with the government team medical directors and regulatory/compliance divisions.
  • Works with Medical Directors to identify and analyze health plan specific clinical policies and guidelines
  • Performs surveillance of clinical content/policy updates for government lines of business and supports maintenance of clinical tools including the Medicare Calculator and Content Retrieval applications.
  • Supports Maintenance of commercial clinical content and medical policy updates that impact clinical authoring and clinical operations
  • Collaborates with IT teams on government clinical review source updates
  • Tracks and logs clinical content project
  • Investigates new technologies and any associated clinical policy, federal or state guidance
  • Collaborates with solution and government programs medical directors and clinical authoring and government programs teams on clinical guideline/medical policy/CMS guidance updates
  • Serves as subject matter expert during integration of clinical policy and/or government clinical content and related processes in existing solution business and as indicted for active implementations
  • Develops subject matter expertise in Medicare and/or Medicaid policy as indicated to support government team business and growth
  • Supports government program medical directors in completion of RFIs and RFPs and other sales and client development activities as needed to support the growth in (membership and revenue) of government business
  • Under the guidance of Clinical Manager, Service Delivery, Policy & Training. partners with and provides backup to medical policy coordinator team members, to serve business needs related to government program operations

Requires a BA/BS in a related field and a minimum of 5 years related experience; or any combination of education and experience which would provide an equivalent background. BSN or MPH preferred. Requires knowledge of medical policy, emerging technology and analysis of emerging evidence.

Preferred Experiences:

  • Knowledge of medical policy
  • Familiarity with Medicare coverage determinations and other Medicare guidance
  • Understanding of Medicaid and its role in the healthcare/insurance industry
  • Familiarity with Medicaid state mandates a plus, but not required
  • Understanding of clinical research & gap analysis
  • Willing and interested in learning about emerging technology
  • Ability to adapt to a fast paced, highly dynamic, and matrixed work environment
  • Familiarity with quality improvement processes
  • Ability to take initiative on projects and work both independently and in team settings
  • Ability to drive work forward and meet project and implementation deadlines
  • Prior experience and working knowledge - computer applications - MS Office Suite (Word, Excel, Outlook, PowerPoint)
  • Willingness to learn additional computer applications as needed to support the role (JIRA, JIRA Align, InRule, IBM Content Navigator)

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $65,200 to $117,360

Locations:  California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company.  The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

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