Clinical Criteria Manager
CareCore National - Bluffton, SC

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Objectives : The Criteria Manager supervises the end-to-end development of CareCore National's clinical criteria and payment policy. The process begins with the research and creation of criteria and policy, continues with the vetting and approval, then operationalization of the criteria and policy into CareCore applications. The Criteria Manager will also audit and ensure the criteria and policy are applied correctly.

Responsibilities: (Included but not limited to)

1. Development of Criteria and Policy
  • Research medical literature for development of new criteria and update of existing criteria
  • Research LCD/NCD compliance for each state
  • State specific coverage rules
  • Liaison with criteria approval and development committees
  • Regular interface with Program Medical Directors for clinical guidance
  • Transform medical concepts into criteria format with reference/bibliography
  • QA UPAD/criteria integration-does it operate in a clinically appropriate manner
  • Evaluate annual CPT code changes and impact to criteria
2. Integration
  • Develop and maintain UPAD pathways
  • Coordinate criteria with health plan CPT code list with Image One function
  • Coordinate annual CT code listing updates with Health Plan functionality of Image One
  • QA UPAD/CPT code list performance-does it operate in accordance with the Health Plan specific CPT code requirements
  • Coordinate letter template types with review types (experimental/investigational, medical necessity, benefit determinations)
3. Document Management-with Supervisory Lead
  • Uniform formatting of criteria document
  • Manage Health Plan/LOB specific versions
  • Maintain documentation of criteria committee activities and appropriate approvals of MAC and Health Plans
  • Regulatory reporting of changes (Maryland) and routine approval (Rhode Island) and some UR license renewals
  • Posting of documents on CCN website
  • Coordinate sharing of criteria with customers
  • Criteria release process
  • Version control
Qualifications: 
Nursing degree or comparable clinical degree or experience 
Experience in managed healthcare policy development or research 
Experience with demonstrated expertise in Microsoft Office Applications (Word, Excel, Visio, Project, and PowerPoint) required. 
Previous experience in a fast-paced, deadline driven office environment 
Experience in one or more of the following areas are preferred: Project management, clinical or policy research, health services management, data analytics, healthcare economics, and / or management consulting. 
Logical with strong verbal and written communication skills essential

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