Remote Medical Policy Clinical Analyst (RN) – California
- Clinical License RN
- State(s) CA
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.
Conduct needed analysis and research regarding medical policies and regulation identification and interpretation activities, as well as assign appropriate medical codes. Support the standardization of appropriate medical policies and codes throughout the organization.
Provides analytic and research support for the Medical Policy Department regulation identification and interpretation activities.
Utilizes knowledge of compliance principles and practices combined with working knowledge of Medicare/Medicaid regulations to develop meaningful and compliant policies.
Researches and interprets complex statutes and regulations and dissects complex organizational and process issues.
Responsible for medical research and developing criteria for medical guidelines in collaboration with Medical Directors to be used by internal & external stakeholders. Interprets benefits & Medicare/Medicaid criteria when needed.
Ensures consistent and accurate interpretation of medical codes for Medicare/Medicaid regulations and supplemental benefits.
Supports the communication functions of the Medical Policy Department.
Serves as a liaison and subject matter expert to multiple business units and leaders throughout the organization as it relates to clinical criterial & coding.
Assists Network Management with reviewing complex and non-standard items/services throughout the contracting process. Researches and evaluates medical claim issues against local and national Medicare/Medicaid policy guidelines.
Maintains professional and technical knowledge by conducting research and by attending educational and technological workshops. This position requires contributions to team effort by accomplishing and sharing related results with other staff.
Contributes to team effort by accomplishing related results as needed.
Exhibits strong interpersonal, critical thinking and analytical skills through positive communication with co-workers, clients & executives.
Other duties as assigned.
Bachelor’s Degree required. BSN preferred.
RN License. CA RN License strongly preferred.
Certification from AAPC (CPC) and/or AHIMA (CCS or CCS-P) preferred.
3+ years of experience in medical coding (CPT, ICD-9, ICD-10) required.
2+ years of analyst experience required.
Experience in the Medicare health plan environment, specifically involving coding and/or compliance work.
Expertise in CMS Medicare/Medicaid regulations required.
Experience coordinating and communicating between contacts in various departments as well as responding to delegated groups.
Proficiency in clinical policy through skills in literature searching and clinical research analysis based on the best available evidence or via direct work experience.
Working knowledge of clinical policies.
Understanding of the managed care industry and market conditions.
High organizational and time-management skills; ability to work independently.
Excellent and clear written and verbal communication skills.
Strong analytical and problem-solving skills.
Ability to work in a cross-functional, professional environment.
Exceptional team player with a strong ability to contribute positively to a team environment with a desire to learn, grow, and empower.
Ability to perform independent research on complex medical topics.
Clinical experience, nursing, therapy, social work background.
Experience writing clinical policy.
Knowledge of NCQA regulations.
Ability to adapt and demonstrate flexibility.
Demonstrated ability to prioritize multiple and competing tasks and work independently and in a team environment.
Ability to work well in a fast-paced and dynamic environment.
What’s in it for you?
- Base salary range: $71,700 – 114,700 / year
- An annual employee bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Ten paid holidays per year, plus 1 additional floating holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution
- Robust employee recognition program
- Tuition reimbursement
- An opportunity to become part of a team that makes a difference to our members and our community every day!
We’re always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.