Senior Medical Policy Implementation Lead

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

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.