Behavioral Health Medical Policy Analyst
About The Position
The Behavioral Health Medical Policy Analyst assists the Chief Medical Director, Medical Management and Utilization Management Operations with technical writing and research related to clinical practices, policies, guidelines, and technology assessments. The role researches consistent evidence-based criteria and authorization rules to support clinical decision-making and assists with technical assessments of new medical technologies and procedures. The analyst supports full disclosure of medical policies to members and providers through web portals and provider manuals, supplements research for the Special Investigations Unit to identify fraud, waste, and abuse, and provides research and criteria to support legal proceedings concerning clinical policy. In partnership with leadership, the analyst works with claims, configuration, and claims dispute teams to support proper implementation of medical policy in the claims system. The role tracks policy timelines and supports annual and as-needed updates to clinical policies—including Clinical Coverage Guidelines (CCGs), Claims Edit Guidelines (CEGs), and Clinical Practice Guidelines (CPGs)—to meet compliance, state, federal, and accreditation requirements. The analyst maintains detailed knowledge of and tracks issues related to medical, pharmacy, and behavioral health policy development and maintenance; supports governing committees; and participates in cross-functional teams addressing key clinical policy issues. Other duties may be assigned.
Requirements
- Bachelor's degree in Medical Technology, Life Sciences, or another related field, or equivalent experience.
- At least 3 years of experience in healthcare, analysis, technical writing, or health administration.
- Experience writing technical publications in the healthcare field.
Nice To Haves
- Registered Nurse (RN) certification is preferred.
Responsibilities
- Research evidence-based criteria and authorization rules to support clinical decision-making.
- Assist with technical assessments of new medical technologies and procedures.
- Support disclosure of medical policies to members and providers through web portals and provider manuals.
- Supplement research for the Special Investigations Unit to identify fraud, waste, and abuse.
- Provide research and criteria to support legal proceedings involving clinical policy.
- Work with leadership, claims, configuration, and claims dispute teams to support proper implementation of medical policy in the claims system.
- Track timelines and support policy updates to meet compliance, state, federal, and accreditation requirements.
- Support annual and as-needed updates to Clinical Coverage Guidelines (CCGs), Claims Edit Guidelines (CEGs), and Clinical Practice Guidelines (CPGs).
- Maintain detailed knowledge of and track issues concerning medical, pharmacy, and behavioral health policy development and maintenance.
- Provide support to governing committees, including the Medical Policy Committee and Claims Payment Policy Committee.
- Participate in cross-functional teams addressing key clinical policy issues.
- Perform other duties as assigned.
Benefits
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off
- Holidays
- Flexible approach to work, with remote, hybrid, field, or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
