The Medical Policy & Special Projects Clinical Analyst serves as the organization's senior clinical subject matter expert for medical policy development, clinical coding strategy, and complex claims configuration initiatives. This role provides strategic leadership in translating evolving clinical practice, regulatory guidance, coding updates, and evidence-based medicine into operational medical policies and claims processing solutions.
The analyst partners across Medical Management, Provider Network, Claims Operations, Information Services, Configuration, Compliance, and Clinical Leadership to evaluate emerging healthcare trends, assess business impacts, and implement enterprise-wide policy and system enhancements. This position leads complex cross-functional initiatives, provides expert consultation on highly specialized clinical issues, and ensures medical policies align with organizational strategy, regulatory requirements, and industry best practices.
Candidates applying to this remote nursing position can live in one of the following states: Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas. What You'll DoMedical Policy Leadership (10%)- Lead the development, interpretation, maintenance, and ongoing evaluation of medical policies using evidence-based clinical literature, national guidelines, regulatory requirements, and coding updates.
- Analyze emerging technologies, new procedures, pharmaceuticals, and clinical treatments to determine policy implications and organizational impact.
- Serve as the clinical authority for complex medical policy interpretation and implementation.
- Recommend policy revisions that improve consistency, quality, compliance, and operational efficiency.
Clinical Coding & Claims Strategy (25%)- Lead evaluation and implementation of ICD-10, CPT, HCPCS, NCCI, CMS, and other industry coding updates impacting claims adjudication.
- Provide strategic oversight for coding edits and clinical business rules within HealthRules and other claims administration systems.
- Partner with Configuration and IT teams to translate clinical requirements into system functionality.
- Identify opportunities to improve automation, reduce manual intervention, and strengthen payment accuracy.
Enterprise Projects & Clinical Consultation (20%)- Lead enterprise-wide initiatives involving medical policy, payment integrity, claims modernization, and regulatory compliance.
- Provide expert consultation to executive leadership and business partners regarding complex clinical policy issues.
- Serve as the clinical liaison across operational, technical, and vendor teams during implementation of strategic initiatives.
- Evaluate business impacts and recommend solutions that balance clinical appropriateness, member experience, provider relationships, and operational effectiveness.
Quality Assurance & Operational Excellence (35%)- Direct clinical validation, user acceptance testing, and end-to-end testing activities for policy and configuration changes.
- Ensure policy implementations are accurate, compliant, and operationally effective prior to production deployment.
- Monitor implementation outcomes and identify opportunities for continuous improvement.
Leadership & Collaboration (10%)- Mentor analysts and other team members on medical policy interpretation, coding methodologies, and clinical best practices.
- Build collaborative partnerships across internal departments and external vendors.
- Lead workgroups and facilitate consensus among stakeholders on complex clinical and operational issues.
- Represent the organization in industry forums, workgroups, and vendor discussions when appropriate.
To Be Considered for This Position, You Must Have- Current Registered Nurse (RN) license in good standing.
- Bachelor's degree in Nursing (BSN) required; Master's degree in Nursing, Healthcare Administration, Public Health, or related field preferred.
- Minimum of 5-7 years of progressive clinical nursing experience in an acute care, specialty care, or other complex healthcare setting.
- Minimum of 3 years of experience in medical policy, utilization management, payment policy, health insurance operations, clinical coding, or related healthcare administration.
- Advanced knowledge of:
- ICD-10-CM/PCS
- CPT
- HCPCS
- National Correct Coding Initiative (NCCI)
- CMS payment methodologies
- Medical necessity criteria and evidence-based clinical practice
- Experience supporting or implementing claims systems, configuration, or healthcare technology solutions.
- Strong analytical, problem-solving, project management, and communication skills.
- Demonstrated ability to lead complex cross-functional initiatives and influence decision-making without direct authority.
The Strongest Candidates Will Also Possess- Certified Professional Coder (CPC), CCS, or comparable coding certification.
- Experience with HealthRules or other healthcare claims processing platforms.
- Experience within a health insurance organization or managed care environment.
- Knowledge of regulatory requirements including CMS, NCQA, URAC, and applicable federal and state healthcare regulations.
- Demonstrated success presenting complex clinical concepts to executive leadership and cross-functional stakeholders.
