Jobs for People with MS: National MS Society

MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.

Medical Policy Ld

Location: This position will work on-site on Torre Chardon Building, Chardon Ave. 350 Suite 500 San Juan, Puerto Rico

Schedule: This position will work a 1st Shift from 8:00 am- 5:00 pm Monday thru Friday. Additional hours or days may be required based on operational needs.

The Medical Policy Ld is responsible for oversight of support functions of the corporate medical policy unit.

How you will make an impact

Primary duties may include, but are not limited to:

• Evaluates and develops clinical policies according to CMS rules and regulations.

• Responds and guides medical staff and other stakeholders’ questions and communicates details about policy and clinical guidelines.

• Monitors day-to-day activities, including work flow, scheduling and PTO.

• Researches and develops new and revised medical policies to ensure that they are in compliance with member contracts, accreditation, and legislation, reflects appropriate medical practice; and are produced and reviewed in a timely manner.

• Ensures all coding associated with medical policy is implemented correctly and in a timely manner.

• Oversees the development and training of coding grids for new and revised medical policies.

• Responsible for yearly CMS Final Rule interpretation, divulgation, and corporate trainings

• Serves as a backup to the medical policy director on various projects relating to medical policy as well as prepare and participate on the medical policy committee.

Minimum Requirements:

• Requires a BA/BS in a related field; 5 years of experience in medical policy; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• BSN preferred.

• Clinical licensure (PR registered nursing license) preferred.

• 2 years of experience in a supervisory or leadership role preferred.

• Knowledge of ICD-9 and HCPCS coding helpful.

• Travels to worksite and other locations as necessary.

• Fully Bilingual (English & Spanish). Must be able to write, read and speak both languages in a proficiency level.