• Prepares research for modality rule sets for annual specialty PAC review by evaluating criteria for clinical appropriateness, alignment with associated LCDs/NCDs, duplication, and potential consolidation

• Prepares comparative review data from health plan medical policies and sends findings to Clinical Review Program Manager for review and consideration

• Reviews all relevant health plan medical policies against HealthHelp criteria and related LCDs/NCDs; proactively presents any differences identified to manager for review and consideration

• Reviews all relevant medical societies’ positions as well as NCCN and FDA guidelines against HealthHelp criteria; proactively presents any differences identified to manager for review and consideration

• Maintains clinical guidelines research and development database for each program on a shared corporate drive

• On at least a monthly basis, reviews Rule Suggestions from Clinical and Physician Reviewers regarding Indications/criteria and updates reporting document for review by manager

• Attends recurring meetings with CSR representatives and management to gain input regarding Indications/criteria needing clarification

• Recognizes and informs management of critical issues

• Adheres to all regulatory requirements and complies with HealthHelp policies and procedures

• Upholds professional standards and performs all work in a manner respectful of others

• Provides a high level of service and support to both internal and external clients

• Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy

• Performs other duties as assigned to meet business needs

Required Skills

• Excellent listening, oral, and written communication/presentation skills

• Ability to communicate complex information in a clear and concise manner

• Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings

• Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines

• Ability to recognize potential and actual problems and work effectively within a team to develop appropriate solutions and implement effective action plans to address the problems

• Demonstrated knowledge and experience in using critical thinking skills

• Proficient with Microsoft Office Suite and Windows

• Proficient with setting up webinars and multi-participate conference calls

Required Experience

• Graduate of an accredited school of nursing
• Current active unrestricted RN or LVN/LPN license in a state or territory of the U.S. required
• Two years of prior experience in direct clinical care or managed care setting required
• Minimum of 1 year of training experience preferred
• Prior experience in medical policy in a health plan or benefit management company highly desirable

WORK ENVIRONMENT

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.

TRAVEL

Dependent on business needs

OTHER DUTIES

Please note that this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

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HealthHelp provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state, and local laws.

• Excellent listening, oral, and written communication/presentation skills

• Ability to communicate complex information in a clear and concise manner

• Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings

• Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines

• Ability to recognize potential and actual problems and work effectively within a team to develop appropriate solutions and implement effective action plans to address the problems

• Demonstrated knowledge and experience in using critical thinking skills

• Proficient with Microsoft Office Suite and Windows

• Proficient with setting up webinars and multi-participate conference calls