Manager, Clinical Policy Optimization

Oscar Health Insurance•New York, NY

51d•Hybrid

About The Position

You will be a key member on our Clinical Policy team within the Office of Clinical Affairs (OCA). You will work cross functional leaders to ensure our policy process is driving affordability goals. You will suspect policy driven opportunities for Medical and Rx driven affordability savings, competitor policy set gap analysis, analyzing policy code level performance data, tracking policy trends and hot spots, identifying policy pathway opportunities. You will be also responsible for tracking and monitoring policy performance and working in partnership with other teams to implement process changes that drive affordability outcomes and improve efficiency. You will report to the Senior Manager, Clinical Policy Development.

Requirements

Bachelor's degree (minimum) in relevant field of study or 4+ years of commensurate experience - B.S.Pharm, PharmD, PA, NP, APRN, BSN, or RN required.
Active, unrestricted clinical license.
4+ years of direct work with clinical policy, with particular emphasis on health insurance policy experience.
4+ years of work experience in utilization management and/or clinical operations
3+ years of experience in designing, implementing and continuously improving programs and processes
3+ years of experience communicating and presenting to stakeholders of all levels
2+ years of experience using Excel/Google Sheets and PowerPoint/Google Slides.
Working knowledge of medical coding (e.g. CPT, ICD-10, HCPCS) and claims and/or Working knowledge of pharmacy coding (e.g., GPI, GSN/CGN, NDC) and claims.

Nice To Haves

MBA or advanced management degree
Experience with commercial or ACA insurance.
Prior work experience analyzing and modeling clinical policy outcomes.
Prior work experience in health insurance and matrixed organizations supporting multiple stakeholders.
Experience translating between clinical and business vocabularies.
Project management certification
Consulting experience

Responsibilities

Track policy performance, and identifies areas for process changes or optimization to drive both affordability and efficiency goals. Accountable for suspecting multiple opportunities to bring forward for further evaluation.
Develop internal tracking and monitor necessary for organizing multiple projects along multiple timelines and deliverables.
Ensure policy opportunities are appropriately tracked and managed through our policy opportunity pipeline.
Assess policy structures to identify functionally unnecessary components, enabling streamlined policy design and implementation.
Create evidence-based recommendations for policy modifications, including appropriate loosening, tightening, or re-routing for additional review.
Incorporate data to drive further iteration and improvement
Bring industry best practices to the policy optimization process to develop organizational frameworks, templates, process organization,and clear points of interconnectivity between policy organization and other teams.
Maintain current knowledge of industry best practices in the space, and work to drive innovation and new approaches.
Perform in-depth review of integrated claims and operational data (medical, pharmacy, lab, auths) to identify cost and trend drivers informing the clinical policy development pipeline.
Build processes that scale across therapeutic areas.
Create executive-ready visualizations tailored to different stakeholder audiences (clinical vs. financial).
Maintain strong relationships, rapport, and lines of communication with stakeholders.
Compliance with all applicable laws and regulations
Other duties as assigned