Description

The hiring range for this role is:
$103,676.95 - $159,759.88

This is the lowest to highest salary we , in good faith , believe we would pay for this role at the time of this posting . We may ultimately pay more or less than the hiring range and t his hiring range may also be modified in the future. A candidate's position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay.

We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching , lifestyle spending account and m any other benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Responsible for overseeing all Utilization Management (UM) and Medical Policy deliverables within the organization. This includes identification, implementation, oversight, management, and evaluation of UM and Medical Policy program functions and initiatives. Serves as a clinical and technical expert, provides technical guidance and education to internal and external business partners regarding UM and Medical Policy clinical criteria and industry standards. Conducts systematic analysis to evaluate evidence-based clinical guidelines to develop and update medical policies. Additionally, reviews and evaluates new benefits, participate in complex projects, and ensures medical policy documentation aligns with benefit design and contractual obligations, supporting program performance assessment and accreditation.

Act as a liaison, resource, and clinical subject matter expert to internal and external business partners. Provide guidance on utilization management and medical policy activities, ensuring the development and implementation of required strategies, programs, and products. Promote and reinforce Plans' accountability for achieving business outcomes, while providing ongoing monitoring, evaluation, and revision of guidelines as needed 25%

Conduct systematic reviews of evidence-based reference policy documents and current clinical literature to develop and update medical policies. Ensure consistency with benefit design, contractual obligations, and program/accreditation requirements. Adhere to the medical policy review cycle schedule, lead content development for draft documents, and prepare and present medical policy content and review procedures to the Pharmacy and Medical Policy Committee for approval 25%

Manage critical escalations that have external visibility and impact member and provider satisfaction. Evaluate options and work with BCBS Plans for resolution. Identify and manage risks, resolve conflicts, and remove barriers that impede Plans' ability to achieve goals and performance expectations 25%

Contribute to cross-functional teams by interpreting utilization data, medical coding, and policy research. Translate trend information into strategic action plans, resulting in value-added resources and programs that address business needs and support program strategic initiatives 15%

Lead background clinical research on current and emerging technology areas, including the FDA approval or clearance status of FDA-regulated products. Synthesize, summarize, and present information to internal and external business partners as the evidence basis for medical necessity and experimental/investigational determinations 10%

Job Overview:

Responsible for overseeing all Utilization Management (UM) and Medical Policy deliverables within the organization. This includes identification, implementation, oversight, management, and evaluation of UM and Medical Policy program functions and initiatives. Serves as a clinical and technical expert, provides technical guidance and education to internal and external business partners regarding UM and Medical Policy clinical criteria and industry standards. Conducts systematic analysis to evaluate evidence-based clinical guidelines to develop and update medical policies. Additionally, reviews and evaluates new benefits, participate in complex projects, and ensures medical policy documentation aligns with benefit design and contractual obligations, supporting program performance assessment and accreditation.

Essential Functions

• Act as a liaison, resource, and clinical subject matter expert to internal and external business partners. Provide guidance on utilization management and medical policy activities, ensuring the development and implementation of required strategies, programs, and products. Promote and reinforce Plans' accountability for achieving business outcomes, while providing ongoing monitoring, evaluation, and revision of guidelines as needed
• Conduct systematic reviews of evidence-based reference policy documents and current clinical literature to develop and update medical policies. Ensure consistency with benefit design, contractual obligations, and program/accreditation requirements. Adhere to the medical policy review cycle schedule, lead content development for draft documents, and prepare and present medical policy content and review procedures to the Pharmacy and Medical Policy Committee for approval
• Manage critical escalations that have external visibility and impact member and provider satisfaction. Evaluate options and work with BCBS Plans for resolution. Identify and manage risks, resolve conflicts, and remove barriers that impede Plans' ability to achieve goals and performance expectations
• Contribute to cross-functional teams by interpreting utilization data, medical coding, and policy research. Translate trend information into strategic action plans, resulting in value-added resources and programs that address business needs and support program strategic initiatives
• Lead background clinical research on current and emerging technology areas, including the FDA approval or clearance status of FDA-regulated products. Synthesize, summarize, and present information to internal and external business partners as the evidence basis for medical necessity and experimental/investigational determinations

Qualifications

Education

• Required Bachelor's Degree in nursing or related field from an accredited university; or equivalent work experience
• Preferred Master's Degree
• Experience
• 5+ Years of experience with Utilization Management and Medical Policy development in a managed care setting Required
• Knowledge Skills and Abilities
• Excellent written and verbal communication skills
  Ability to translate complex, technical and/or quantitative information in clear, concise, and understandable documents of presentation
  Advanced project management skills for planning and executing multiple projects and a detail orientation to ensure compliance with accreditation standards and accuracy of statistics
  Demonstrated ability to identify and create strategies that support initiatives and translate these into strategic action plans
  Ability to work well in an interdisciplinary clinical team environment
  Demonstrated ability to foster strong working relationships with customers and business stakeholders and contact
  Demonstrated ability to handle multiple projects, prioritizing critical aspects/tasks, working under pressure and meeting deadlines
  Ability to lead independent research
  Technical proficiency with information technologies (e.g. Microsoft Office) and literature-search databases
  Demonstrated abilities in data analysis, synthesis, and reporting, including systematic analysis of clinical literature
  Ability to conduct comparative analysis of external medical policies, with detailed analysis of specific clinical indications
  Demonstrated ability to understand complex medical technology assessments and detailed analysis of specific clinical indications in medical policies
• Certifications & Licenses
• Required: RN-CS - RN Certified Clinical Specialist -
• Preferred: CPHM - Certified Professional in Healthcare Management - AIHM
• Preferred: Certified Professional Coder (CPC) - AAPC
• Preferred: Accredited Case Manager (ACM) - ACMA

Extra Posting information:

A minimum of four years of experience with Utilization Management and Medical Policy development in a managed care setting.
Experience with URAC/NCQA accreditation requirements. Experience presenting information to large audiences (town hall calls, professional conferences, etc.), both virtually and in-person. Experience in leading cross-functional work
Experience related business experience which demonstrates knowledge and understanding of PPO operations, business practices and processes, as well as knowledge of corporate goals.

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