Medical Policy Implementation Specialist

Job Summary

To support the development of medical policies, the full-time Medical Policy Implementation Specialist will conduct audits of medical claims, analyze data for policy recommendations, and serve as a resource for staff regarding medical policy implementation, all while working remotely.

Key responsibilities:

• Conduct audits and investigations of medical claims to ensure compliance with regulations and guide policy development
• Provide direction to benefits systems analysts for accurate configuration of benefits and maintain coding databases
• Produce reports on utilization trends and address claims payment errors through audits and reviews

Required qualifications:

• High School Diploma or Equivalent (GED) required
• Minimum of 2 years of relevant experience in medical claims or policy implementation
• Experience with CPT coding and benefit configuration preferred
• Ability to conduct research and analyze medical records for compliance and coverage eligibility
• Familiarity with healthcare policy and coding guidelines