Medical Policy Analyst

Description

MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.

Medical Policy Analyst 

Location: This position will work a hybrid model (1-2 days/week onsite in office). When reporting to the office, the location will be on MMM Holdings, Kennedy Building located on 411 Calle Segarra Marginal Kennedy, San Juan, Puerto Rico.

The Medical Policy Analyst is responsible for medical research and developing criteria for medical policies to be used by review, utilization, and core system for claims adjudication and payment.

How you will make an impact

Primary duties may include, but are not limited to:

• Researches and evaluates medical claim issues against local and national Medicare policy guidelines.
• Reviews new and updated codes for accuracy and consistency.
• Researches relevant studies and reviews articles for development of local medical review policies and for responses to inquiries from providers.
• Works with Medical Directors on development of local medical review policies.
• Assists operations by reviewing complex and non-standard type of claims as related to a policy.
• Codes changes into claims systems using national coding structure for processing accuracy and clinical appropriateness once Medical Policy has been established by physician plan committee.
• Serves as a liaison to business units for new requirements on Company initiatives that will require configuration on the Medical Policy system.   .
• Researches questions and issues from internal physicians and nurses as they relate to developed medical policies.
• Responds to internal and external requests that seek written clarification of a general or specific policy question.
• The response may be reiteration of an established policy, a redefinition of the current policy, or research to determine a new or revised policy.

Minimum Requirements

• Requires a BA/BS degree and a minimum of 2 years related experience including clinical experience and may include operations experience; or any combination of education and experience which would provide an equivalent background.
• Typically requires active state RN license.
• Nursing degree preferred.
• Travels to worksite and other locations as necessary.

Preferred Skills, Capabilities, and Experiences:

• Experience in clinical policies configuration and research.
• Strong healthcare claims processing expertise and medical terminology knowledge.
• Bilingual (English – Spanish)

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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 an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 elevancehealthjobssupport@elevancehealth.comfor assistance.