Remote within ID, OR, WA or UT. Candidates outside of these states will not be considered.
Primary Job Purpose
Identify, appraise, and summarize scientific literature and clinical practice guidelines for the development and implementation of medical policies to be used primarily by Medical Directors, internal clinical staff and external provider partners. Provide leadership among the Medical Policy team and across the organization by leading meetings, developing and implementing process improvement activities, conducting training sessions, and reviewing key deliverables produced by the team.
General Functions and Outcomes
Researches, critically appraises, and summarizes scientific literature and clinical practice guidelines to develop medical policy and clinical practice guidelines.
Develops medical policies and presents research and policy recommendations to the Medical Policy Workgroup including the medical directors for approval.
Provides guidance and internal trainings on medical policy implementation and interpretation for various internal uses such as clinical editing, prior authorization, retrospective claim review, or appeals.
Represents Cambia in various meetings with external medical professionals and public forums in relation to clinical research and medical policies. Develops and circulates written summaries of the research and relevant discussions.
Documents all research processes and medical policy decisions.
Exceptional ability to communicate effectively, verbally and in writing.
In-depth knowledge of the following: anatomy and physiology/disease processes; medical terminology; genetics; interpretation and application of medical policies; and clinical utilization management.
Familiarity with CPT, ICD and HCPCS coding for medical technologies, procedures, and services.
Knowledge of techniques for conducting literature searches, analyzing and interpreting scientific medical literature for quality of study design and reliability of data.
Ability to compile data from scientific literature and clinical practice guidelines in a presentable format for internal and external medical professionals. Present research summaries and policy recommendations for approval.
General computer skills (including use of Microsoft Office, Excel, PPT).
Ability to exercise judgement, initiative and discretion in sensitive and confidential matters.
Normally to be proficient in the competencies listed above
Medical Policy Research Analyst would have a Master's degree in a health science related field (e.g., nursing, pharmacy, public health, epidemiology, biostatistics), two years clinical or clinical research experience, two years' experience developing medical policies/assessing medical technologies, and health plan experience or equivalent combination of education and experience. Current licensure or professional certification relevant to the work (e.g., RN) preferred.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career focused on making the health care experience simpler, better, and more affordable for people and their families, consider joining our team at Cambia Health Solutions. Cambia is a total health solutions company that is deeply rooted in a 100-year legacy of transforming the industry and the way people experience health care. We had our beginnings in the logging communities of the Pacific Northwest as innovators in helping workers afford health care. That pioneering spirit has kept us at the forefront as we build new avenues to improve access to and quality of health care for the future. Cambia is committed to delivering a seamless, personalized health care experience for the next 100 years.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.