Medical Policy/Benefits Analyst
AlohaCare - Honolulu, HI

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In collaboration with AlohaCare’s Medical Directors, researches, develops, and maintains AlohaCare’s policies and guidelines regarding medical necessity and appropriateness. Develops AlohaCare’s benefit coverage policies using Evidence of Coverage information, CMS and DHS contractual requirements, and health plan reimbursement policies. Performs all activities related to the appropriate administration of benefits ensuring compliance with Medicaid and Medicare coverage guidelines. Responds to requests from internal departments for information and training on AlohaCare’s medical necessity guidelines and coverage of benefits.

Essential Responsibilities:
  • Researches national and/or locally accepted medical necessity guidelines, solicits input from appropriate staff and develops initial AlohaCare medical necessity guidelines for review with the Medical Directors
  • Works with the Medical Directors on research and development of medical policies to guide benefit coverage decisions; develops clear, concise documentation of policy and benefit requirements
  • Maintains and assures periodic review of all medical coverage policies
  • Uses a variety of resources including but not limited to online information/databases, Medicare and Medicaid guidelines and requirements
  • When required, obtains policy/guideline approval from applicable committee(s)
  • Communicates approved medical necessity and benefit coverage policies/guidelines throughout the organization
  • Maintains a library of approved policies and guidelines on SharePoint and assures timely notification to appropriate staff of new or revised guidelines
  • Researches and interprets changes in benefit coverage and communicates any required benefit setup changes to Business Analysis staff
  • Serves as primary contact for benefit related questions and issues
  • Consults as needed with the senior leader responsible for plan benefit designs to create and maintain benefit coverage and exclusions documents that serve as reference for staff
  • Works with Medical Directors and clinical staff to assure consistent application of approved guidelines
  • Provides medical guidelines and benefit coverage related training to staff
  • Maintains benefit plan design and performs regular review of benefit design to ensure proper setup and the accuracy of member cost share applied during claims processing
  • Documents results of reviews and works with Business Analysis Team on benefit configuration
  • Pursues professional development as necessary to enhance job performance.
Position Requirements:
  • Bachelor's degree in Nursing or Pharmacy or equivalent
  • 3-5 years of experience with managed care or health insurance environment, including experience with medical policy and benefit coverage development
  • Familiar with CMS and DHS contract requirements
  • Knowledge of healthcare system and factors that affect adoption and implementation of new and emerging healthcare technologies and procedures
  • Strong literature searching skills and ability to synthesize complex information
  • Working knowledge of policies and procedures (specifically in healthcare)
  • Ability to quickly synthesize volumes of information on health technologies and clinical trials in wide variety of clinical areas
  • Analytical and detail oriented
  • Able to effectively communicate with others at all various levels
  • Able to problem-solve and communicate solutions
  • Must be capable of working under tight deadlines, with the flexibility to work on several projects concurrently
  • Able to type multi-page documents
  • Able to work in a high stress environment at times, with pressure of deadlines and multiple projects
  • Computer literate; intermediate to advanced proficiency with Windows-based programs and applications
Preferred Requirements:
  • Clinical Training
An Equal Opportunity Employer

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