Job Information
Healthfirst Sr Clinical Policy Analyst in Hybrid, New York
Duties/Responsibilities:
Support the Medical Policy and Clinical Utilization Management (UM) Governance Committee Chairs, committee members, and related workgroups by organizing all meeting materials (e.g. meeting minutes, presentations, etc.), tracking follow-up activities, and preparing/maintaining related reports and documentation.
Facilitate the Healthfirst medical and clinical policy processes, including developing new policies, monitoring industry policy trends and tracking annual policy renewals/approvals.
Collaborate on policy reviews with committee stakeholders and clinical business unit stakeholders
Engage with, support and spearhead the policy work that will inform Medical and Clinical strategy
Perform editorial formatting and review of policies, confirm policy references, and obtain necessary approvals from key governance committee members.
Review the appropriate UM or related clinical and medical policies, job aids/procedures, and correspondence and make recommendations for policy creation/revision and/or committee action
Ensure parity in processes across clinical and medical departments
Conduct ad hoc medical condition research per Medical Director and/or UM Clinical Director requests.
Collaborate with the Regulatory, Compliance, Legal and Clinical departments to ensure deliverables adhere to local, state, federal, and Healthfirst-specific compliance and regulatory guidelines.
Monitor any Corrective Action Plans (CAPs) and related committee/workgroup activities through to completion
Identify potential organizational risks and help facilitate process improvements
Support accreditation submissions, regulatory surveys, and internal audits
Ensure timely and accurate responses to any requests for information or audits.
Build sustainable relationships of trust through open and interactive communication with cross-functional teams at all levels within Healthfirst.
Comply with HIPAA requirements and maintain Protected Health Information (PHI) confidentiality of member, provider, medical and departmental information.
Additional duties as assigned
Minimum Qualifications:
Associates degree from an accredited institution
Registered Nurse (RN), Licensed Social Worker (LCSW or LMSW)
Work experience using and interpreting medical terminology and concepts
Knowledge of Centers for Medicare and Medicaid Services (CMS) and/or New York State Department of Health (NYSDOH) regulations
Previous regulatory/compliance experience within a managed care environment
Experience with Clinical guidelines including but not limited to Milliman Care Guidelines, Hayes Clinical Guidelines, Encoder Pro, EMEDNY,CMS National and Local Coverage Determinations
Preferred Qualifications:
Bachelors degree
Knowledge of compliance and regulatory guidance/regulations across the Medicaid, Medicare, MLTCPs, and Commercial Lines of Business.
Experience working in a fast-paced environment that requires flexibility and adapting to change while managing multiple priorities simultaneously.
Work experience requiring strong verbal and effective written communications while demonstrating exceptional grammar and spelling skills.
Experience presenting and communicating to cross-functional groups within an organization
Problem-solving, initiative taking, multitasking and critical thinking skills
Experience with MS Office Suite, MS Teams, MS Outlook, SharePoint, Logic Manager, and Adobe Acrobat.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.