Senior Manager, Medical and Clinical Claim Policy and Integration

About the Role

The 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. This individual provides direction and support for system configurations and necessary operational assistance to ensure effective policy implementations. The role offers broad exposure and close collaboration with all business units, including Medical Management, Network Management, Claims, Operations, IT, Sales and Account Management, and Legal. This is a remote role.

Responsibilities

• Review, update, evaluate, and develop medical and clinical claims policies for the Commercial medical insurance segment to promote quality, optimize utilization, and manage costs effectively.
• 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 the 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 CES rules and configuration.
• Prepare 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.
• Lead 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.
• Maintain and update JIVA automation code sets, rules, and configurations to support accurate claims processing, utilization management workflows, benefit administration, and medical policy implementation.
• Work closely with the Benefits team in configuring new clients and collaborating with the High Dollar team for coding, Prior Authorization (PA), and benefit questions.

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.
• Excellent communication skills, organized, and able to write clearly.
• Enjoys challenges associated with decision support algorithms and attention to detail, including embedding logic in narrative prose and comfort with numbers.
• 5 years’ experience in healthcare 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.
• Bachelor’s degree with an advanced or specialized degree in healthcare, public health, epidemiology, or health policy preferred (e.g., Public Health, Pharmacy, Allied Health Professional, Nursing). Certified medical coder preferred.
• Familiarity with state and federal mandates, FDA, and other regulatory requirements for medical devices, drugs, and biologics.
• Proficient with Microsoft Word and Excel.

About the Company

At Brighton Health Plan Solutions, LLC, our people are committed to improving how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect, and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs. We enable them to solve today’s healthcare challenges with flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, proprietary provider networks, and an innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with customizable tools to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives.

Company Mission: Transform the health plan experience—how healthcare is accessed and delivered—by bringing outstanding products and services to our partners.

Company Vision: Redefine healthcare quality and value by aligning the incentives of our partners in powerful and unique ways.