Medical Policy Implementation Analyst Sr

Cambia Health Solutions, Inc
Portland, Oregon
Apr 01, 2024
Apr 06, 2024
Role Type
Position Type
Full Time
Practice Setting
Work Mode
On-site, Remote
Employment Type
Medical Policy Implementation Analyst Sr

Remote in ID, OR, WA, UT

Primary Job Purpose

The Medical Policy Implementation Analyst Sr identifies, recommends, and publishes clinical policy criteria for all lines of business. Organizes and maintains policies so they are accessible to internal and external customers. Consults with Medical Directors and other internal staff on policy development and implementation as well as system application.

General Functions and Outcomes

  • Effectively drafts, interprets, and applies medical policies and assists in the workload distribution of the medical policy team. Present policy criteria recommendations to Medical Directors and other internal staff for approval.
  • Appropriately applies procedural and diagnostic coding (CPT, HCPCS, and ICD) to policy criteria with an understanding of the impact on policy implementation.
  • Implements, maintains, and publishes on the web a library of clinical criteria that is accessible to internal and external customers.
  • Works with system users and databases to ensure consistent application and implementation of policies.
  • Develops and maintains related department procedures.
  • Ability to manage project tasks, set objectives, goals, and develop schedules while meeting deadlines and documentation requirements for accreditation standards with minimal supervision.
  • Interprets the policy criteria for entry into CWQI Guideline Modification Module for clinical review.
  • Advise and communicate with internal and external stakeholders regarding policy questions, decisions, outcomes.

Minimum Requirements

  • In-depth knowledge of anatomy and physiology, disease processes, medical and CMS policies, MCG criteria, clinical utilization management, case management or behavioral health management.
  • Competency interpreting and applying CPT, ICD, and HCPCS coding for medical technologies, procedures, and services.
  • Familiarity with utilization review and clinical claim review process.
  • Demonstrated analytical ability to identify problems, develop solutions, and implement a chosen course of action with internal and external medical professionals and other experts.
  • Strong organization skills, independent worker, and proficiency in Microsoft Office and various Web-based internet applications.
  • Ability to communicate effectively, verbally and in writing.
  • 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 key member of project team.

Normally to be proficient in the competencies listed above

Medical Policy Implementation Analyst Sr would have a Bachelor's degree in health science or related field (e.g., nursing, public health) and 5 years of experience in working with medical policies and 3 years of direct clinical experience or equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

  • Certified Professional Coder (CPC) preferred. If no CPC currently, employee must attain CPC within 6 months of hire.
  • Register Nurse (RN) license (must have a current unrestricted RN license)