Medical Policy & Special Project Clinical Analyst - RN

What You'll Do

• Medical 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.

Requirements

• 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, 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.

Qualifications

• 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.