The Medical Policy & Coding Consultant I (MPCC I) plays a vital role within the Medical Policy & Coding (MPC) department, contributing to the development, evaluation, and maintenance of evidence-based medical policies and coding protocols that align with regulatory standards and organizational goals. Under the guidance of senior consultants and MPC leadership, this position supports strategic initiatives that enhance clinical integrity, coding accuracy, and cost-effective care delivery. The MPCC I serves as a subject matter liaison across multiple departments to promote appropriate utilization, provider alignment, and regulatory compliance.

• Research, draft, and maintain medical policies that incorporate clinical best practices, regulatory mandates (CMS, NCQA, DOH), payer-specific positions, and medical literature from authoritative sources including FDA and specialty societies.
• Ensure accurate integration of CPT, HCPCS, ICD-10, CDT, and revenue coding into each policy, supporting downstream functions such as claims processing, prior authorization, and reimbursement alignment.
• Analyze claims data before and after policy implementation to assess trends, identify utilization patterns, and inform policy refinement and coding updates.
• Serve as a policy and coding consultant on cross-functional initiatives including vendor collaborations, new code assessments, reimbursement projects, appeals, and utilization review strategies.
• Manage timelines for policy updates and ensure timely review cycles to support Clinical Advisory Committee deliberations, policy configurations, and publication schedules.
• Collaborate closely with internal stakeholders including Medical Directors, Pharmacy, Product Development, Provider Network, IT&D, and Vendor Management to ensure policies are clinically appropriate and operationally feasible.
• Contribute to compliance efforts by monitoring evolving regulatory requirements and participating in quality improvement initiatives to align policies with state and federal mandates.
• Assist in developing and documenting departmental SOPs and workflows to promote efficiency and consistency in policy development and coding application.
• Provide support in response to internal and external inquiries regarding policy coverage, coding clarification, or regulatory interpretation.

Skills:

• Demonstrated proficiency of researching, analyzing, and presenting data.
• Demonstrated ability to communicate effectively and professionally in written and verbal form with internal stakeholders and ensure quality of both communications including, but not limited to, formatting, spelling, punctuation and grammar and excellent proof and edit skills.
• Demonstrated exceptional organizational skills and attention to detail.
• Knowledge of Centers for Medicare Services (CMS), FEP, NCQA, DOH and partnering insurance plans policies and regulations. Ability to organize work and complete assigned work schedule and set priorities with minimal direct day-to-day supervision.
• Ability to adjust to changing job requirements and priorities to meet dynamic needs and workflow.
• Demonstrated proficiency in Microsoft Office Suite including but not limited to Outlook, Word, Excel, PowerPoint & Access. Working knowledge in SharePoint a plus.
• Demonstrated ability to perform basic arithmetic, percentage, and statistical calculations.

Knowledge:

• Current, working knowledge of clinical practice and/or health research.
• Working knowledge of medical coding, to include, ICD10, CPT, CDT, HCPCs and revenue codes.
• Working knowledge of Government regulatory and accrediting requirements (PPACA, FEP, CMS, Pennsylvania state regulations, NCQA, URAC, DOH and Medical Assistance).
• Advanced understanding of Medical Terminology.

Experience:

• Strong clinical, policy, or research background; 3-5 years’ experience.
• Minimum of 3 years’ similar work experience, preferably in a managed care /health insurance related position.

Education and Certifications:

• Current and non-restricted clinical license
• The position requires obtaining an American Association of Professional Coders (AAPC) Medical Coding certification. The AAPC certification course will be offered at management’s discretion once the employee meets certain criteria showing course readiness. Continuing education credits must be satisfied to maintain the certification.
• Prefer bachelor’s degree

Physical Demands:

• The employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to physically sustain a work week sometimes exceeding 40 hours per week.
• The employee must occasionally lift and/or move up to 5-10 pounds. 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 occasionally lift and/or move up to 5 pounds.

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.