Medical Policy Analyst

Summary

Join Wellmark as a Medical Policy Analyst and contribute to ensuring members receive appropriate evidence-based healthcare services. Research, analyze, develop, and maintain medical policies for all Wellmark products using evidence-based research and analysis of medical technologies. Improve research methodologies in the decision-making process to ensure policies are grounded in evidence-based healthcare. Thoroughly research and comprehend large volumes of clinical literature and guidelines to draw clear conclusions and make concise policy recommendations. Communicate complex healthcare information clearly, both in writing and verbally, to cross-functional teams. Manage multiple priorities with precision and attention to detail, working both independently and collaboratively.

Requirements

• Bachelor’s degree in health sciences related field (e.g., nursing, pharmacy, public health, epidemiology, biostatistics, etc.), or direct and applicable work experience
• Completion of an accredited registered nursing program and active and unrestricted Registered Nurse (RN) license in Iowa or South Dakota; individual must be licensed in the state in which they reside
• Minimum of 4 years of related health plan, research, or clinical experience in researching, analyzing, and presenting synthesis of clinical data
• Knowledge of commercial health insurer systems, medical terminology and current healthcare issues
• Expertise and demonstrated strong ability in reading comprehension to conduct research of large volumes of information such as clinical guidelines/literature/studies and draw conclusions and make concise recommendations with clear rationale to support
• Strong verbal and written communication skills. Ability to effectively condense large volumes of complex, often conflicting information and communicate concisely and clearly the analysis as it relates to a medical policy and report out rationale to the medical policy team
• Ability to present voluminous amounts of information to cross-functional areas within organization with unique ability to take complex health care information and present in a way which will be understood
• Demonstrated success in roles requiring strong time management and organizational skills with marked attention to detail. Ability to prioritize effectively and manage multiple deliverables
• Strong interpersonal relationship-building skills to quickly build rapport, credibility, and collaborative partnerships with medical policy team members, clinical peers, leaders, and any stakeholders across the organization
• Self-starter who works well independently and collaboratively with many different internal teams across the organization
• Technical acumen with the ability to learn new systems quickly. Proficient in Microsoft Office Suite and policy management software

Responsibilities

• Keep up-to-date on industry knowledge, new treatments, and maintain awareness of emerging technologies through independent reading of research materials, trade journals, and other pertinent literature
• Conduct research using standard, established sources, the Internet, and relevant peer-reviewed articles. Analyze the limitations of the research and the strength of the evidence. Interpret and summarize findings of the research, including demographic, statistical and scientific information, for internal and external stakeholders. Review and perform comprehensive comparison of third party medical criteria, policies, clinical practice guidelines and third-party technology assessments to determine impact of changes and whether there is need for modifying Wellmark policy positions
• Collaborate and coordinate with internal (medical directors, provider economics, legal, pharmacy, clinical appeals, etc.) and external stakeholders (e.g. healthcare providers, academic and scientific professionals, and national and local professional organizations) in medical policy research and development process
• Develop and maintain clear and concise evidence-based medical policies as assigned to you. Provide detailed analysis, reports, and recommendations for policy position and administration related to medical policy to Director of Medical Policy and/or Senior Medical Director of Medical Policy  based on analysis and interpretation of medical literature research and multiple other data points
• Ensure medical policy content is reviewed and researched on an annual basis at minimum and updated as needed to remain current with scientific evidence, clinical studies and other evidence-based data points
• Serve as a consultant by gathering relevant information, integrating internal systems, and making innovative recommendations, for policy implementation
• Comply with regulatory standards, accreditation standards and internal guidelines; remain current and consistent with the standards pertinent to the Medical Policy team
• Perform analytics review of utilization data for each medical policy assigned to you with proficiency and a keen eye towards disparity which warrants further investigation. Provide detailed analysis and/or reports related to medical policy utilization to Director of Medical Policy and/or Senior Medical Director of Medical Policy as requested
• Provide oversight to ensure that policy content is written to also include clear coding guidance and recommendations to ensure payment outcomes reflect the intent of the medical policy. With an understanding of Current Procedural Terminology (CPT) coding and International Classification of Diseases (ICD-10), make recommendations to medical policy team’s certified professional coders (CPC) on coding of policy based upon intent of policy
• Mentor, teach and counsel cross-functional peers within utilization management (appeals, prior authorization, special inquiries, sales, etc.) on medical policy content, coding and intent of the medical policy
• Other duties as assigned

Preferred Qualifications

• Direct medical policy analysis experience with Blue Cross Blue Shield Association (BCBSA) and/or a Blue Cross Blue Shield (BCBS) plan or other commercial health insurer
• Utilization management knowledge; demonstrates understanding of how medical criteria is utilized

Benefits

Remote work, flexible hours