Medical Policy Clinical Spclst
Full Time
Mountlake Terrace, WA
$82,700 - $140,700 a year
Posted
Job description
Join Our Team: Do Meaningful Work and Improve People’s Lives
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership.
Forbes ranked Premera among America’s 2023 Best Midsize Employers
because we are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!
About the role of Medical Policy Clinical Specialist
The Medical Policy (MP) Clinical Specialist is a critical role in Premera, responsible for the development and maintenance of medical policies to guide coverage determinations for new and developing technology, pharmacologic agents or health care services where concerns regarding safety, efficacy or wide variance in utilization exist. The MP Clinical Specialist monitors and updates policies associated with programs that may be implemented by contracted vendors on behalf of the organization. Medical policies may apply to all lines of business and geographic regions or may be specific to a line of business. The MP Clinical Specialist works closely with non-clinical support staff and the clinical review department to identify and resolve any issues related to policy language, criteria, or the operational implementation of a policy.
What you’ll do
:
- Drive individual medical policy development and revision to ensure that company policies reflect the most current published scientific literature and are usable for clinical staff.
- Monitor the external environment regarding new and evolving medical technology by following on-line updates from Hayes, Agency for Healthcare Research & Quality (AHRQ), National Institute of Health (NIH), Washington State Health Care Authority (WA-HTCA), Oregon Health Evidence Review Commission (OR-HERC), Center for Medicare and Medicaid Services (CMS) and other sources.
- Interpret statistical analyses of clinical studies and published statements from professional societies. Translate that information into summary statements for inclusion in policy documents.
- Liaise with Clinical Appeals Department to regularly review data from same specialty and independent review organizations. Utilize the data to inform the need to revise medical policy and coverage criteria.
- Analyze qualitative and quantitative data to measure the impact of medical policy and utilization activities to determine the business and member value of medical policies. Conduct internal research to assist business decisions regarding archival of policies.
- Present medical policy summaries for discussion and clinical vetting at the Medical Policy Committee, the Pharmacy and Therapeutics Committee, or other committees as requested.
- Develop and present clinical education materials for review staff (doctors and nurses) to support appropriate use and interpretation of policies and clinical review criteria sets.
- Use clinical knowledge and expertise, and internal research when needed, to respond to external and internal inquiries.
- Act as a clinical liaison representing Medical Policy to cross departmental committees and work groups working on benefits, legislative mandates, preventive care and other issues.
- Serve as Premera liaison with Blue Cross Blue Shield Association Office of Clinical Affairs and represent the Premera on implementation and topic selection calls.
- Other duties as assigned.
What you’ll bring:
- Bachelor's degree in health services or clinical science (such as Nursing, Pharmacy, Public Health, Epidemiology, Biostatistics, Genetics, Health Technology). (Required)
- Registered Nurse, Physician’s Assistant, or Nurse Practitioner with five (5) years' clinical experience. (Required)
- Four (4) years of health plan experience in utilization management to include any of the following: pre-service review, post services review, and/or clinical appeals. (Required)
- Medicare Advantage experience. (Required)
- Master’s degree in health care or business-related field. (Highly Preferred)
- Management or project management experience. (Preferred)
- Health plan experience in developing medical policies or criteria sets. (Preferred)
- Familiarity with ICD-10 and CPT coding. (Preferred)
- Familiarity with claim payment processes. (Preferred)
- Superior clinical writing skills.
- Excellent analytical, research and critical thinking skills. Ability to evaluate scientific studies across the spectrum of medical specialties.
- Excellent oral and written communication skills with ability to communicate well across all levels of the company.
- Proficient in a Windows environment utilizing Outlook, Word, Excel, PowerPoint, and SharePoint.
- Proven ability to drive projects to completion and effectively facilitate work groups.
- Proven ability to work both independently and as a member of a team to prioritize work.
- Able to manage multiple complex projects and priorities.
#LI-RS1
What we offer
- Medical, vision and dental coverage
- Life and disability insurance
- Retirement programs (401K employer match and pension plan)
- Wellness incentives, onsite services, a discount program and more
- Tuition assistance for undergraduate and graduate degrees
- Generous Paid Time Off to reenergize
- Free parking
Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.
If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.
The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.
National Salary Range:
$82,700.00 - $140,700.00
National Plus Salary Range:
$93,500.00 - $159,000.00
- National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.
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