Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The MPC Manager is responsible for providing oversight and management of Capital’s Medical Policy and Coding (MPC) department activities and staff to ensure full compliance with all applicable regulatory and accreditation requirements. The Manager will provide oversight and clinical leadership to the adoption of new medical policies and the annual review, update and approval of existing medical policies. This position will provide oversight of organization-wide coding support and consultative activities performed by department staff. Serving as the MPC subject matter expert, the Manager will develop and maintain collaborative relationships with key internal and external stakeholders involved or intersecting with MPC processes.

• Provide oversight and management of Capital’s Medical Policy and Coding (MPC) department activities and staff to ensure full compliance with all applicable regulatory and accreditation requirements. Serve as the MPC subject matter expert across the organization.
• Provide oversight and clinical leadership to the adoption of new medical policies and the annual review, update, and approval of existing medical policies. Ensure policy alignment with high quality, evidence-based literature and guidelines and any applicable state and/or federal mandates..
• Provide oversight of coding support and consultative activities performed by MPC staff. Oversee the new code review process.
• Participate and/or lead Capital committees involved or intersecting with the work of the MPC team. Leverage these committees in the evaluation of new medical technologies and new applications of existing technologies and provide opportunity for multidisciplinary group review, discussion, and final approval.
• Maintain collaborative relationships with key stakeholders in the MPC process to understand how their business processes intersect and/or support the MPC process. Ensure effective and timely processes are in place to address concerns in the application of medical polices, especially from utilization management and/or appeals staff. Anticipate, address and resolve questions and concerns timely.
• Ensure appropriate internal (stakeholder) and external (provider, member) communication on medical policy changes in full compliance with all regulatory, contractual, and accreditation requirements. Coordinate and oversee responses to internal and external inquiries on medical policy position/coverage.
• Ensure accurate application of medical policies in alignment with policy position, including proper coding and configuration within internal Capital systems.
• Maintain oversight and routine updates to comprehensive departmental administrative policies that fully document the processes to develop, implement, and maintain medical policies, timely coding, and other departmental functions.
• Collaborate with applicable vendors with whom Capital may partner in the development, implementation, and ongoing maintenance of specialty medical policies.
• Participate in the annual preparation and regular monitoring of the MPC budget.
• Participate in strategic projects and initiatives that align with corporate strategy and priorities.
• Maintain strong awareness and oversight of department staffing and workload, identifying, proposing and implementing solutions or escalating opportunities for increased efficiency, effectiveness, and modernization of processes.
• Perform other related duties and assignments as directed.

Skills:

• Exceptional critical thinking and problem-solving skills
• Strong electronic research skills.
• Ability to work independently, delegate appropriately, manage time effectively,
• Ability to sustain and lead a team
• Ability to communicate efficiently both orally and in writing
• Ability to perform electronic clinical research
• Proficiency in MS Office; Word, Excel. and PowerPoint.
• Demonstrated superior cross-functional collaboration.
• Demonstrated ability to work and interact with all levels both within and outside of Capital.

Knowledge:

• Knowledge of medical billing and insurance industry norms, policies and procedures
• Knowledge of health plan regulatory requirements, including CMS, NCQA, and the DOH.
• Knowledge of current and emerging medical treatment modalities and utilization management practices
• Knowledge of personnel and performance management and workload planning concepts.

Experience:

• 5 years clinical experience required with two years management experience.
• 1 year staff, team lead or project lead experience
• 3 years experience in a managed care/health insurance environment is preferred.
• Experience coordinating and leading complex, multi-departmental initiatives and driving results to achieve shared goals.

Education and Certifications:

• Bachelor’s degree required.
• Clinical licensure required (RN, LPN, LCSW, LPC, or comparable).
• Coding certification required. Certified Professional Coder (CPC) via the American Association of Professional Coders (AAPC) is strongly preferred.
• Current valid Pennsylvania drivers license to travel to and from provider/member/customer locations.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Travel: 5% or less.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.