About The RoleThe Senior Manager of Medical and Clinical Claim Policy and Configuration is a senior level decision maker responsible for the content and management of Medical and Claim Policies. Also provides direction and support for system configurations as well as necessary operational assistance to ensure effective policy implementations. This individual will gain broad exposure and work closely with all business units including Medical Management, Network Management, Claims, Operations, IT, Sales and Account Management, and Legal.
*This is a remote role.Primary Responsibilities- Review, update, evaluate and develop medical and clinical claims policies for Commercial medical insurance segment to promote quality, optimize utilization and cost to make them effective for the business.
- Take responsibility and work closely with Healthcare Economics, Medical Management, Network Management, Claims, Operations, IT, Sales & Account Management, and Legal to implement policies designed to support the effective management of medical expenses and promote quality care.
- Collaborate with IT and other departments on business and technical requirements involving policies.
- Develop and maintain Prior Authorization list for Commercial business.
- Manage Medical and Clinical Claim policy web content and publication.
- Serve as the subject matter expert for Claims Editing Solution (CES) and lead initiatives involving medical and claim policy including but not limited to CES rules and configuration.
- Prepares analyses and recommendations for medical policy updates and new code implementation for Medical Director review. Responsibilities include researching applicable CPT/HCPCS/ICD codes, benchmarking industry and payer practices, evaluating benefit and operational impacts, and providing recommendations for code handling, coverage determinations, and benefit integration.
- Leads the digitization and maintenance of medical policies, including converting policies into electronic formats, configuring policy content within designated systems, ensuring version control and accuracy, and supporting ongoing updates to align with regulatory requirements, business needs, and operational workflows.
- Maintains and updates JIVA automation code sets, rules, and configurations to support accurate claims processing, utilization management workflows, benefit administration, and medical policy implementation.
- Work closely with Benefits team in configuration of new clients and working with High Dollar team for coding, PA and benefit questions
Essential Qualifications- Expert understanding of Medical Claims operations including medical insurance benefits, medical policy, claims policy, quality assurance, utilization review, and medical cost management.
- Solid understanding of claim processing including pricing and code editing.
- Strong organizational and planning skills to manage multiple priorities and meet required deadlines.
- Good communicator, organized, and able to write clearly
- Enjoys the challenges associated with decision support algorithms and the attention to detail it requires.
- This job requires the ability to embed logic in narrative prose and be comfortable with numbers.
- 5 years' experience in health care administration, managed care, or medical insurance field required
- 2+ years' experience creating, writing, or managing clinical, claims, or healthcare technical policies and procedures is preferred.
- Experience working with medical and claims policy reference sources such as CPT/HCPCS/ICD/DRG coding manuals, Specialty Society Guidelines, National Guidelines Clearinghouse materials, CMS and CMS Intermediary policies, and Commercial Health plans policies, among others.
- Bachelors with an advanced or specialized degree in healthcare, public health, epidemiology, or health policy preferred (Public Health, Pharmacy, Allied Health Professional, Nursing etc.), certified medical coder preferred.
- Familiarity working with state and federal mandates, and FDA and other regulatory requirements for medical devices, drugs and biologics.
- Comfortable with Microsoft Word and Excel.
