Medical Policy Implementation Analyst Sr
About The Position
The Medical Policy Implementation Analyst Senior is part of Cambia’s Health Service Organization Medical Policy team. The role identifies, recommends, drafts, interprets, and publishes clinical policy criteria for all lines of business, organizing and maintaining policies so they are accessible to internal and external customers. The analyst consults with Medical Directors and other internal staff on policy development, implementation, and system application. The position uses utilization and appeals patterns, scientific literature, clinical practice guidelines, and evidence summaries to inform policy criteria and policy updates. It applies procedural and diagnostic coding, works with system users and databases to support consistent policy application, and maintains a web-accessible library of clinical criteria and related department procedures. The analyst also manages project tasks and communicates with stakeholders regarding policy questions, decisions, and outcomes. This is a hybrid role requiring three days per week in the office. Offices are listed in Salt Lake City, Boise, Fargo, Portland, Vancouver, Renton, Medford, Burlington, Lewiston, Little Rock, and Springdale. Candidates are preferred if they live within commuting distance of specified offices or are willing to relocate.
Requirements
- Bachelor’s degree in health science or a related field, such as nursing or public health, and five years of experience working with medical policies and three years of direct clinical experience, or an equivalent combination of education and experience.
- Current unrestricted Registered Nurse (RN) license.
- Certified Professional Coder (CPC) certification; if not currently certified, the employee must attain CPC within six months of hire.
- Knowledge of anatomy and physiology, disease processes, medical terminology, and medical and surgical procedures.
- Familiarity with CPT, ICD, and HCPCS coding for medical technologies, procedures, and services.
- Familiarity with utilization review and clinical claim review processes.
- Knowledge of coverage policies, policy application hierarchy, and search methodologies.
- Analytical ability to identify problems, develop solutions, and implement a chosen course of action with internal and external medical professionals and other experts.
- General computer skills, including Microsoft Office, Outlook, and web-based internet applications.
- Strong organizational skills and ability to work independently.
- Ability to communicate effectively verbally and in writing.
- In-depth knowledge of interpreting medical and CMS policies, MCG criteria, and clinical utilization management, case management, or behavioral health management.
- Competency interpreting and applying CPT, ICD, and HCPCS coding for medical technologies, procedures, and services.
- Knowledge of techniques for conducting literature searches and identifying relevant clinical practice guidelines.
- Ability to appraise, summarize, and present research and clinical practice guideline recommendations to inform policy criteria.
- Demonstrated success with project management and ability to serve as a key member of a project team.
Nice To Haves
- Knowledge of CMS Medicare coverage guidelines and compliance rules.
- Experience with AI tools and technologies to enhance productivity and decision-making in professional settings.
Responsibilities
- Draft, interpret, and apply medical policies, and assist with workload distribution for the medical policy team.
- Present policy criteria recommendations to Medical Directors and other internal staff for approval.
- Track utilization and appeals patterns to inform policy criteria changes and new policies.
- Apply CPT, HCPCS, and ICD procedural and diagnostic coding to policy criteria, considering the impact on policy implementation.
- Implement, maintain, and publish a library of clinical criteria on the web for internal and external customers.
- Work with system users and databases to ensure consistent application and implementation of policies.
- Develop and maintain related department procedures.
- Manage project tasks, set objectives and goals, develop schedules, and meet deadlines and accreditation documentation requirements with minimal supervision.
- Interpret and summarize scientific literature and clinical practice guidelines to inform medical policy drafting and approval.
- Use evidence and guideline summaries to develop and update clinical policy criteria.
- Interpret policy criteria for entry into the CWQI Guideline Modification Module for clinical review.
- Advise and communicate with internal and external stakeholders regarding policy questions, decisions, and outcomes.
Benefits
- Competitive salary and generous benefits.
- Bonus opportunities.
- Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
- Annual employer contribution to a health savings account.
- Paid time off that varies by role and tenure, in addition to 10 company-paid holidays.
- 401(k) retirement plan with a company match and potential discretionary contribution based on company performance.
- Up to 12 weeks of paid parental time off, subject to eligibility requirements.
- Wellness programs with participation rewards.
- Employee Assistance Fund.
- Commute and parking benefits.
- Work-from-home options for most roles, subject to internet requirements.
- Career growth opportunities.
- Cambia-supported community outreach programs.
- Employee resource groups.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
