In collaboration with the Medical Directors and the Office of Clinical Affairs, the Medical Policy Manager
is responsible for the overall development, coordination and management of the Plan's medical policies. This includes developing corporate medical policy and coordinating the Plan’s medical technology assessment process in accordance with state, federal and accrediting organization requirements, including NCQA, and managing the medical policy development and revision function from research stage to writing to committee(s) approval to external communication. This individual also manages external relationships with the Plan’s technology assessment vendors.
Key Functions & Responsibilities:
- Responsible for the Plan’s medical technology assessment process and ensuring compliance
with applicable regulatory organizations - Develops new clinical coverage criteria policies from initial draft to final edits for review and
approval at Medical Policy Clinical Technology Assessment Committee (MPCTAC) and Quality
Improvement Committee meetings, as well as review at Utilization Management Committee
meetings - Chairs, develops agenda for and coordinates all related functions for MPCTAC Committee
meetings - Coordinates all external policy reviews with either Plan providers or through the external vendor,
and presents final recommendations to committees - Coordinates the request for data analysis for new and annual review of clinical coverage criteria
policies - Responsible for annual review and updates to all clinical coverage criteria and coordinates
policy review calendar - Responsible for internal website maintenance of clinical coverage criteria, including uploading of
new policies and archiving old ones - Responsible for external website maintenance of clinical coverage criteria when any policy has
been changed or updated or new policies have to be added in collaboration with IT department. - Responsible for developing network notifications pertaining to clinical criteria updates in
collaboration with marketing - Assists with the development of the annual inter-rater reliability tool for clinical staff and Plan
medical directors that are applicable to clinical coverage criteria - Develops and maintains external specialist list for review of clinical policies.
- Plan contact for the Hayes Medical Technology vendor
- Performs appropriate research for the Plan’s medical directors to support clinical decisions for
individual case determinations - Provides clinical input and support to the member grievance and appeal process
- Regular and reliable attendance is an essential function of the position.
Education & Experience:
Required:
- Bachelor’s Degree in Nursing or the equivalent combination of education training and
experience. - 6 years of experience in managed care setting, including utilization management and quality improvement, required.
- Strong experience in health policy development.
Preferred/Desirable:
- Masters degree in health related field preferred.
- 7+ years of clinical experience.
- Experience with Medicaid recipients and community services.
- Experience with FACETS, CCMS, Interqual or other healthcare database.
Competencies, Skills, & Attributes:
- Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
- Demonstrated strong organization and time management skills.
- Able to work in a fast paced environment; ability to multi-task.
- Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications.
- Strong analytical and clinical problem solving skills.