Full-Time Medical Policy Supervisor
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Job Description
The Company:
AlohaCare is a local, non-profit health plan which provides comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. In the true spirit of Aloha, AlohaCare supports, cares and serves the health care needs of Hawaii’s residents and specializes in care for the medically underserved and medically fragile. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.
The Culture:
AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.
AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare’s strong commitment to support local Hawaiian families is practiced with our employees by reinforcing a healthy work/home balance. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, monthly appreciation events, quarterly all-staff meetings and annual galas. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.
These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.
The Opportunity:
Position Summary:
Manage medical policy development, maintenance, and implementation. Supervise or lead clinical policy research, medical procedure and diagnostic codes, performance dashboards, new technology, interdisciplinary projects, and services contracts. This position reports to Chief Medical Officer (CMO).
Primary Duties & Responsibilities:
- Supervise, develop, and maintain medical policies to guide benefit coverage decisions in Utilization Management and all clinically related departments. Lead and provide ongoing clinical policy research on national, regional, and local clinical practice guidelines and medical necessity criteria. Provide education and training across the Clinical Division.
- Identify specific and relevant ICD, CPT, and HCPCS medical codes into medical policies in response to changes in Medicaid and Medicare regulations and law, payment models for health services, and risk-adjusted care coordination activities as related to medical policies. Act as Subject Matter Expert for clinical coding issues, updates, projects, and clinical practice guidelines.
- Supervise, develop, maintain, and report dashboards related to medical policy development and implementation with metrics and actionable analytics for Clinical Division-wide operation. Collaborate with all clinical departments, including Utilization Management, Quality Improvement, Medicare Care Coordination, Behavioral Health, Pharmacy, Travel and Clinical Services Support, and Transition of Care. Apply business intelligence software, such as MedeAnalytics and MicroStrategy, and utilize claims administration and care management systems, such as QNXT and GuidingCare. Provide education and training across the Clinical Division.
- Supervise clinical research, data analytic, and payment projects across the company that impact on medical policy formation and implementation by using research tools and medical coding and clinical knowledge through collaboration with Directors and Managers of Data Analysis, Business Analysis, and hospitals and Community Health Centers in underserved areas across the state.
- Orient medical policies to be consistent with Patient Centered Medical Home (PCMH), Home & Community Based Services (HCBS) programs, Community Health Centers (Federal Qualified Health Centers (FQHC)), and other large provider groups related to health disparities and geo-cultural diversity, as well as the standards of the National Committee on Quality Assurance (NCQA) accreditation.
- Monitor contracts related to evidence-based research tools, peer to peer physician review, nurse advice line, and clinical technology in compliance with the requirements of Medicaid and Medicare contracts and NCQA accreditation, regarding medical policy development and implementation.
- Identify the need for new medical policies related to procedural and diagnostic technology, as well as new or advanced Durable Medical Equipment, and compliant with reference to Medicaid and Medicare utilization criteria and NCQA standards.
- Staff the Practitioners Advisory Committee (PAC) which solicits feedback from active practitioners from the community health centers and other large provider groups in terms of medical policy development and implementation.
Required Competencies & Qualifications:
Master’s Degree
- 3-5 years of experience with clinical care, health plans, hospitals, or any other healthcare institutions
- Minimum 3 years of experience with NCQA standards, Medicare/Medicaid programs.
- Minimum 3 years of experience using ICD and CPT codes.
- Minimum 3 years project management experience in a health insurance company or related healthcare facilities
- Knowledge of emerging healthcare technologies and procedures and ability to synthesize large and diverse information in a wide variety of clinical areas.
- Experience of care management in the community, such as Home and Community Based Services, or Patient-Centered Medical Home.
- Strong online searching, analytical and research skills and ability to summarize complex information.
- Strong ability in analyzing large data sets by applying analytical and statistical tools and software.
- Master computer software, including Microsoft Office, tools of developing workflow, dashboard, data report , presentation software.
- Able to work independently and also able to collaborate with staff at various levels for team work and project.
- Certified Professional Coder (CPC) by American Academy of Professional Coders (AAPC)
Preferred Qualifications:
- Master Degree in Health Administration, Nursing, or Public Health. Or Doctor Degree in Pharmacy
- Clinical practice or clinical training in broad departments.
Physical Demands/Working Conditions:
- Requires operation computer workstation, including keyboard and video display terminal.
- Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record), disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.
How to Apply:
For more information, please contact Josie Gesteuyala, HR Generalist
Phone: 808.973.6339
Email: jgesteuyala@alohacare.org
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