Corporate Medical Policy Analyst

Amerihealth Caritas • ,

1d • Remote

About The Position

The Corporate Medical Policy Analyst researches, develops, and maintains evidence-based clinical policies to promote consistent medical necessity determinations, support quality health outcomes, and ensure compliance with enterprise, Medicare, Medicaid, and ACA Exchange requirements at state and federal levels. The Analyst conducts clinical research, competitor analysis, and peer reviews in response to requests from Medical Directors, Utilization Management, Compliance, Legal Affairs, the Clinical Policy Committee, Markets, and organizational leadership, and addresses gaps in existing criteria and emerging standards of care.

Working independently, the Analyst evaluates clinical literature, professional society guidelines, regulatory requirements, and industry best practices to develop clear, transparent, and defensible medical policies. The role collaborates with internal and external stakeholders, presents policy recommendations to the Clinical Policy Committee, provides evidence-based rationale for proposed decisions, and responds to questions and concerns in support of policy approval and governance.

The position is remote and scheduled Monday through Friday, 8:30 AM to 5:00 PM EST. Remote associates must have reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload. Associates residing in states where reimbursement is required by contract, law, or regulation may submit for reimbursement.

Requirements

• Bachelor's degree.
• At least 3 years of experience as an independent clinician.
• At least 3 years of experience researching and writing clinical policies, preferably for a payor.
• Well-developed technical and clinical writing skills, with research experience and published works available for review.
• Strong critical-thinking and analytical skills, including the ability to evaluate and synthesize extensive clinical research, evidence-based literature, and regulatory guidance into concise, structured, defensible policies.
• Strong written, verbal, and presentation skills, including the ability to explain complex clinical information, present evidence-based recommendations to governance committees, and articulate and defend policy decisions.
• Ability to work independently, manage competing priorities, deliver high-quality work with minimal supervision, and proactively identify issues and improvement opportunities.
• Proficiency with MS Office and research databases such as Cochrane and ScienceDirect.
• For the remote role, access to reliable high-speed internet with a minimum of 50 Mbps download and 5 Mbps upload.

Nice To Haves

• Master's degree (MS/MSN or higher) in health policy, public health, epidemiology, or another clinical specialty.
• Physician Assistant, Advanced Practice Nurse, Pharmacist, or other master's-level clinical licensure.
• Coding experience or Certified Professional Coder (CPC) certification.

Responsibilities

• Conduct annual clinical policy updates, including competitor and utilization analysis; review clinical literature, regulatory and safety information, FDA information, and new evidence; recommend revisions, retirement, major change, or no major change; coordinate internal peer review; present and defend updates to the Clinical Policy Committee; and prepare policies for final publication.
• Develop new clinical policies for requested topics, emerging technologies, regulatory changes, and inventory gaps by analyzing competitors and utilization, synthesizing research and guidelines, coordinating internal peer review and with requesters, presenting and defending recommendations to the Clinical Policy Committee, and preparing policies for publication.
• Compare Medicaid and commercial benchmark policies; identify emerging topics and policy-development priorities; analyze coverage criteria, exclusions, documentation requirements, and evidence; and maintain dated, source-linked comparisons.
• Identify new and revised clinical practice guidelines, assess whether changes warrant policy updates, maintain guideline inventories and source links, and prepare recommendation summaries and documents for CPC/QAPIC and publishing.
• Review delegated utilization-management vendor criteria and revisions for overlap or conflict with internal clinical policies, and summarize changes in memos for QAPIC and other state approval committees.
• Research active CPT/HCPCS codes applicable to policies; verify fee schedule status, coverage requirements, benefit limits, and authorization rules across the Enterprise; identify and resolve policy, coding, claims, and authorization inconsistencies; and update policy code lists and code/policy crosswalks.

Benefits

• Flexible work solutions, including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off, including holidays and volunteer events.
• Health insurance coverage for associates and their dependents starting on Day 1.
• 401(k).
• Tuition reimbursement.

What This Job Offers

• Job Type: Full-time