Medical Policy Implementation Analyst Sr

Cambia Health Solutions, Inc.; United States; Hybrid; USD 80,000 - 130,000; Full time

Job summary

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

The role focuses on identifying, recommending, and publishing clinical policy criteria across lines of business for easier member health journeys. You'll work with Medical Directors and staff, manage multiple policies, apply CPT/ICD/HCPCS coding, and publish criteria on the web.

Qualifications

• Bachelor's degree in health science or related field.
• RN license (active/unrestricted) preferred.
• CPC certification or commitment to obtain within 6 months.

Responsibilities

• Draft, interpret and apply medical policies and support workload distribution.
• Track utilization patterns and appeals to inform policy changes.
• Apply CPT/HCPCS/ICD coding to policy criteria with awareness of impact.
• Publish and maintain a web library of clinical criteria.
• Coordinate with system users and stakeholders to ensure policy consistency.

Skills

Anatomy & physiology knowledge

Medical terminology

CPT/ICD/HCPCS coding familiarity

Utilization review & clinical claim

Policy development & application

CMS Medicare guidelines knowledge

Literature review & guideline apprais

Project management

Communication skills

AI tools familiarity

Education

Bachelor's degree in health science

RN license

CPC certification

Tools

Microsoft Office

Web-based applications

Job description

Medical Policy Implementation Analyst Sr### Medical Policy Implementation Analyst SrApply: Fargo, ND: Salt Lake City, UT: Arkansas: Medford, OR: Renton, WA: Full time: Posted Yesterday: R-7044**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.** **Build a career with purpose. Join our** **Cause** **to create a person-focused and economically sustainable health care system.****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. Are you energized by the opportunity to translate complex clinical policies into accessible guidance that directly impacts members' health care experiences? Are you comfortable managing multiple clinical policies across different lines of business while maintaining meticulous organization and accessibility for diverse stakeholders? Then this role may be the perfect fit **What You Bring to Cambia:** **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.* Implements, 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. #Li-HybridPay 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. The full salary range is $80,000 - $130,000 and the bonus target is 10%. The expected salary range is $85,000 - $115,000. 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 $72,000 - $117,000 and the bonus target is 10%. The expected salary range is $76,500 - $103,500.