Medical Policy Implementation Analyst Sr

Cambia Health Solutions; Fargo (ND); Hybrid; USD 72,000 - 117,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401(k) with company match

Paid time off and holidays

Wellness programs

Job summary

Cambia Health Solutions, Inc. is seeking a Medical Policy Implementation Analyst Senior to join our Health Service Organization policy team.

You will identify, publish and maintain clinical policy criteria across lines of business, consulting with Medical Directors and staff to support policy development and system application. You will apply CPT/ICD/HCPCS coding, review literature and guidelines, and communicate policy decisions to internal and external stakeholders while coordinating with

Qualifications

• Bachelor's degree in health science or related field and 5 years of experience with medical policies
• CPC certification, within 6 months if not current
• RN license required (current, unrestricted)

Responsibilities

• Drafts, interprets and applies medical policies for the policy team.
• Present policy recommendations to Medical Directors for approval.
• Track utilization patterns to inform policy changes.
• Apply CPT/HCPCS/ICD coding to policy criteria and assess impacts.
• Maintain and publish a library of clinical criteria on the web.
• Collaborate with system users and databases to ensure policy consistency.
• Develop and maintain department procedures.
• Manage projects with deadlines and accreditation standards.
• Summarize literature and guidelines to inform policy criteria.

Skills

Medical policy knowledge

CPT/ICD/HCPCS coding

Policy development

Analytical skills

Project management

AI tools experience

Communication skills

Research methodology

Education

Bachelor's degree in health science or related field

RN license

CPC certification or plan to attain within 6 months

Tools

Microsoft Office

Job description

Medical Policy Implementation Analyst Senior

Hybrid role (3 days/week in office) at our Salt Lake City, Boise, Fargo, Portland, Vancouver, Renton, Medford, Burlington, Lewiston, Little Rock and Springdale offices. Preference will be given to current employees and candidates who reside within a commutable distance from our Salt Lake City, Boise, Fargo, Lewiston, Little Rock and Springdale offices or who are willing to relocate.

Who We Are Looking For:

Every day, Cambia’s dedicated team of Medical Policy Implementation Analyst Senior are living our mission to make health care easier and lives better. As a member of the Health Service Organization (HSO) Medical Policy team, our Medical Policy Implementation Analyst Senior 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 – all in service of making our members’ health journeys easier.

Qualifications

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

Skills and Attributes

• Demonstrated knowledge of the following: anatomy and physiology/disease processes; medical terminology, medical and surgical procedures.
• Familiarity with CPT, ICD and HCPCS coding for medical technologies, procedures, and services.
• Familiarity with utilization review and clinical claim review process.
• Demonstrated knowledge of coverage policies, policy application hierarchy and search methodologies.
• Knowledge of CMS Medicare coverage guidelines and compliance rules desirable.
• Demonstrated analytical ability to identify problems, develop solutions and implement a chosen course of action with internal and external medical professionals and other experts.
• General computer skills (including use of Microsoft Office, Outlook) and various Web-based internet applications.
• Strong organization skills, and an independent worker.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.
• Ability to communicate effectively, verbally and in writing.
• In-depth knowledge of the following: anatomy and physiology/disease processes; interpretation of 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.
• Knowledge of techniques for conducting literature searches and identifying relevant clinical practice guidelines.
• 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.

What You Will Do at Cambia

• 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.
• Tracks patterns in utilization and appeals to inform policy criteria changes and new policies.
• Appropriately applies procedural and diagnostic coding (CPT, HCPCS, and ICD) to policy criteria with an understanding of the impact on policy implementation.
• Implants, 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.
• Interpret and summarize scientific literature and clinical practice guidelines in order to inform the drafting and approval of medical policies.
• Uses evidence and guideline summaries to develop and update clinical policy criteria.
• 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.

Compensation & Benefits

#Li-Hybrid Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.

National pay structure — applies to the Boise, Portland, Salem, Seattle/Renton/Tacoma, Burlington, Vancouver, and Salt Lake City metro areas.

Regional pay structure — applies to North Dakota and to Idaho, Oregon, Washington, and Utah locations outside the metro areas listed above.

• The full salary range is $80,000 - $130,000 and the bonus target is 10%.
• The expected salary range is $85,000 - $115,000.
• The full salary range is $72,000 - $117,000 and the bonus target is 10%.
• The expected salary range is $76,500 - $103,500.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.
• Learn more about our benefits.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

• Work alongside diverse teams building cutting‑edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.
• We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

Equal Opportunity Employer

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email [e-mail]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

Cambia Health Solutions is a family of companies headquartered in Portland, Oregon, working to make healthcare simpler, more affordable and more person‑focused. Through our regional health insurance plans, innovative technologies and strategic investments, we are delivering consumer‑centric solutions that:

• Help people achieve better health and well‑being
• Make healthcare more available, affordable, and personalized
• Are easily understood by everyone

We put people at the heart of everything we do. Our company reaches more than 70 million Americans nationwide, including more than 6 million people enrolled in our regional health plans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices.

Interested in driving accessibility, affordability and quality health care for real people?