Clinical Policy Specialist

CareSource•Dayton, OH

About The Position

Job Summary: The Clinical Policy Specialist I provides clinical policy support to both new and established lines of business (LOB) through managing state submissions, submitting Communication Request Forms, tracking processes, and ensuring clinical policy compliance. Essential Functions: Assist Clinical Policy Project Specialist to execute, monitor and support new lines of business throughout the entire clinical policy project lifecycle. Audit, monitor and prepare clinical policies for NQCA, state, and internal audits Develop, implement, configure, and maintain decision trees, workflows, documentation and monitoring protocols to operationalize clinical policies and criteria in a timely manner Participate in department initiatives and projects including implementation of new document management systems Support the development and maintenance of enterprise Clinical Policy programs (i.e., policy assessments, department newsletter, network notification communications) Collaborate with interdisciplinary team members to achieve team goals Participate in risk assessment and continuous improvement activities, as needed Follow Workfront procedures to coordinate and implement changes ensuring regulatory, compliance, and business goals are met Ensure timely submission, accurate documentation, and tracking of all Communication Request Forms and network notifications for clinical policies to be published on external websites Monitor the CareSource public website to ensure policies are accurately published and accessible Document and track state submissions and approvals, keeping consistent communication with Clinical Policy team, leadership, and regulatory as necessary. Track and trend clinical policy metrics (i.e., CRF, archives, revisions) reported monthly, quarterly, end of year, and as needed Assist with Policy Tech functions to streamline policies through the entire end-to-end process Support the operational processes of the Clinical Policy Governance Committee (CPGC) Create agendas, document, and store minutes and pertinent records for all assigned team meetings as necessary Maintain and update job related internal policies and procedures applicable to Clinical Policy process and workflows Provide coverage for both Policy Coordinator and Policy Project Specialist when needed Perform any other job duties as requested

Requirements

Bachelor’s degree or equivalent years of relevant work experience is required
Minimum of two (2) years of healthcare policy experience is preferred
Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
Detail-oriented and critical thinker
Proficient in documentation management systems
Proficient in SharePoint
Proficient in creating and delivering effective PowerPoint presentations
Knowledge of medical terminology, pharmacy claims processing, and healthcare administration
Ability to interpret clinical information
Excellent verbal and written communications skills
Presentation and decision-making skills
Excellent organization and tracking skills
Strong problem-solving skills
Ability to communicate effectively with employees at all levels of the organization.
Ability to work autonomously and in a team environment
Ability to handle multiple priorities/projects simultaneously

Nice To Haves

Health plan experience is preferred
SharePoint management experience preferred
Documentation Management system experience is preferred
Basic Six Sigma or Lean certification preferred

Responsibilities

Assist Clinical Policy Project Specialist to execute, monitor and support new lines of business throughout the entire clinical policy project lifecycle.
Audit, monitor and prepare clinical policies for NQCA, state, and internal audits
Develop, implement, configure, and maintain decision trees, workflows, documentation and monitoring protocols to operationalize clinical policies and criteria in a timely manner
Participate in department initiatives and projects including implementation of new document management systems
Support the development and maintenance of enterprise Clinical Policy programs (i.e., policy assessments, department newsletter, network notification communications)
Collaborate with interdisciplinary team members to achieve team goals
Participate in risk assessment and continuous improvement activities, as needed
Follow Workfront procedures to coordinate and implement changes ensuring regulatory, compliance, and business goals are met
Ensure timely submission, accurate documentation, and tracking of all Communication Request Forms and network notifications for clinical policies to be published on external websites
Monitor the CareSource public website to ensure policies are accurately published and accessible
Document and track state submissions and approvals, keeping consistent communication with Clinical Policy team, leadership, and regulatory as necessary.
Track and trend clinical policy metrics (i.e., CRF, archives, revisions) reported monthly, quarterly, end of year, and as needed
Assist with Policy Tech functions to streamline policies through the entire end-to-end process
Support the operational processes of the Clinical Policy Governance Committee (CPGC)
Create agendas, document, and store minutes and pertinent records for all assigned team meetings as necessary
Maintain and update job related internal policies and procedures applicable to Clinical Policy process and workflows
Provide coverage for both Policy Coordinator and Policy Project Specialist when needed
Perform any other job duties as requested