Health Plan Data and Medical Policy Clinician - Remote

📋 Description

• • Analyze and interpret complex health plan data, coverage, payment, and coding policies to provide critical insights and recommendations to Utilization Management (UM) leadership and other Clinical Programs at Martin’s Point Healthcare.
• • Leverage extensive clinical and coding knowledge, combined with advanced analytical expertise, to guide and educate leaders on optimizing health plan data from various operational perspectives.
• • Inform and influence decisions regarding system configuration, data feed requirements, and the development of robust reporting specifications to enhance operational efficiency and clinical effectiveness.
• • Develop and maintain comprehensive medical policies essential for Utilization Management and Medical Necessity determinations, ensuring alignment with current evidence-based practices and regulatory standards.
• • Play a key role in the development and ongoing maintenance of the Prior Authorization (PA) list, meticulously reviewing codes for clinical relevance and potential return on investment (ROI).
• • Conduct in-depth analysis of current and emerging treatments, including drugs, devices, and procedures, assessing their potential financial and operational impact on the organization.
• • Perform detailed data management and analysis, extracting and manipulating data from the Enterprise Data Warehouse (EDW) and other relevant sources to support strategic decision-making.
• • Contribute to the ongoing development, review, editing, and training of Health Management Department (HMD) standards and clinical guidelines, collaborating with HMD leadership to incorporate updates from regulatory entities, process improvement initiatives, and new plan products.
• • Provide crucial clinical and coding business knowledge to internal and external system applications and analytics teams, ensuring accurate system configuration, data feed requirements, and reporting specifications.
• • Manage the quarterly and yearly coding updates process, including thorough research, informing and supporting UM leadership on policy/criteria changes, and making recommendations for authorization requirements and business initiatives.
• • Ensure UM system application business rules and decision support tools effectively support business objectives and regulatory requirements by collaborating closely with internal systems application staff and external UM vendors.
• • Assist with health plan system benefit configuration and provide timely updates to the IT department regarding coding and benefit changes.
• • Actively participate in technology and system planning and enhancement projects, recommending and tracking technology modifications that support care management, disease management, and utilization management programs, including UM application business rules.
• • Represent the clinical department in various Health Plan/Delivery System committees, focus groups, and strategic interdepartmental initiatives, serving as a subject matter expert.
• • Act as a primary subject matter expert resource for other analysts across the organization, providing in-depth clinical and coding knowledge.
• • Take a lead role in tracking the progress and activities of key initiatives, ensuring successful implementation and outcomes.
• • Maintain and manage the SharePoint site dedicated to storing, monitoring, and maintaining Health Management Department policies, procedures, and guidelines, ensuring accessibility and version control.
• • Serve as a key resource for escalated authorization requests, claims disputes, coding/coverage questions, auditing, and prepayment claims reviews, providing expert guidance and resolution.
• • Become an expert user of third-party analytical tools and reporting platforms, recommending tools and methodologies for organizational-level deployment, departmental use, and external partner collaboration.
• • Lead the Medical Policy Committee, driving the development and updating of evidence-based medical policies that are strictly aligned with industry standards and regulatory requirements.
• • Regularly evaluate the Prior Authorization List, conducting code reviews and providing ROI support to ensure the list remains effective and aligned with clinical and financial goals.
• • Collaborate with cross-functional teams to ensure seamless integration of clinical policies and data insights into operational workflows and system functionalities.
• • Stay abreast of the latest advancements in healthcare policy, medical coding, and data analytics to continuously enhance the organization's approach to utilization management and clinical program development.
• • Contribute to a culture of continuous learning and improvement by sharing knowledge and best practices with colleagues.