Manager Policy & Implementation
Cambia Health Solutions

Job Info

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Manager Policy & ImplementationRemote only within (ID, OR, UT, WA)

Supervises This position plans, organizes and directs medical policy activities including policy development and consultation with the medical policy the team and acts as a manages the resources for Policy & Implementation staff. Oversees and coordinates team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through the maintenance and publication of reimbursement policy and the assessment, approval and implementation of clinical edits in support of medical and reimbursement policy or other industry standards. Plans the implementation of policy in partnership with clinical, claims and utilization management. Provides critical analysis of guidelines development and management of staff. Interacts with all levels of management, internal and external vendor, clients, providers and outside consultants.

Responsibilities

• Assigns and prioritizes work, sets goals, and coordinates daily activities of the team. Provides regular updates and communication to staff through 1:1 and team meetings.
• Plans, directs, organizes and manages activities surrounding policy and implementation.
• Designs, manages and implements administrative policies and procedures related to policy and implementation.
• Monitors individual and team results to ensure work is completed in a timely manner, in accordance with department standards and procedures, and is in compliance with medical and reimbursement policy guidelines.
• Assists in development of productivity and quality standards. May conduct or participate in compliance audits and report audit findings. Identifies and implements process improvements as needed.
• Acts as a resource for staff and others. Appropriately escalates issues and partners with other departments to resolve issues and remove barriers.
• Provides effective leadership and directs the work of professional policy and implementation staff in research, analysis and critical evaluation.
• Participates in the hiring process, provides on-going coaching, employee development and writing of performance reviews. Develops and maintains desk reference guides on work procedures. Ensures new hires complete necessary training. Assesses training needs and plays an active role in development of staff.
• Completes special projects as assigned and may provide back-up support to staff as needed.
• Provides initial direction to Policy Implementation team concerning potential data analysis strategies related to medical policies, including identification of potential implementation strategies.
• Identifies and recommends changes related to Regence and group-specific medical policy implementation,
• Manages ongoing communication with Reimbursement Policy team, Healthcare Services teams and Provider Services concerning policy implementation requirements and strategies.
• Provides leadership to Claim Business team responsible for resolving issues around policy and payment, including implementation of workflows due to policy changes and updates to Claim processing documentation.
• Provides recommendations to Preauthorization, Payment Review, and other partners.
• Serves as a resource for RFP development related to policy processes and issues.
• Partners with educational resource materials for use by members, staff and providers.
• Maintains clinical competency and keeps current on coding and billing practices and industry trends particularly related to clinical editing.
• May develop and present educational updates internally or to other departments.
• Seeks ideas and opportunities for continuous improvement; determines which opportunities should be pursued and implements improvements as appropriate.
• Supports the business and system implications between medical policy, editing, coding, reimbursement, and benefit teams.

Requirements

Demonstrated competency in setting priorities for a high performing team and overseeing work outputs and timelines.

Ability to communicate effectively, verbally and in writing including with members, employer or provider groups.

Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely).

Demonstrated experience in recognizing problems and effectively resolving complex issues.

Familiarity with health insurance industry trends and technology.

Demonstrated proficiency with claims and other clinical data, corporate reimbursement and medical policies, and the application of clinical editing software

Ability to apply best practices and designated standards.

Ability to understand, translate and communicate technical and complex ideas and situations to a wide variety of audiences.

Normally to be proficient in the competencies listed above:

Supervisor Manager of Policy and Implementation would have a bachelor's degree in business or health-related field, 5 10 years of healthcare industry experience, and 2 5 years leadership experience or equivalent combination of education and experience.

Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.

If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.

This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards.

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

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