Medical Policy & Special Project Clinical Analyst – RN

This is a fully remote position, open to applicants in Florida, +6 more states.

📋 Description

• Oversee the creation, interpretation, maintenance, and continuous assessment of medical policies utilizing evidence-based clinical literature, national guidelines, regulatory standards, and coding updates.

• Assess emerging technologies, novel procedures, pharmaceuticals, and clinical treatments to understand their policy implications and organizational effects.

• Act as the clinical expert for intricate medical policy interpretation and execution.

• Suggest policy amendments that enhance consistency, quality, compliance, and operational effectiveness.

• Direct the assessment and implementation of ICD-10, CPT, HCPCS, NCCI, CMS, and other industry coding updates that influence claims processing.

• Offer strategic leadership for coding edits and clinical business rules within HealthRules and additional claims management systems.

• Collaborate with Configuration and IT teams to convert clinical requirements into system functionalities.

• Recognize opportunities to enhance automation, minimize manual processes, and improve payment accuracy.

• Lead company-wide initiatives related to medical policy, payment integrity, claims modernization, and regulatory compliance.

• Provide expert advice to executive leadership and business partners on intricate clinical policy matters.

• Act as the clinical liaison among operational, technical, and vendor teams during the execution of strategic initiatives.

• Assess business impacts and propose solutions that balance clinical appropriateness, member experience, provider relationships, and operational efficiency.

• Manage clinical validation, user acceptance testing, and comprehensive testing activities for policy and configuration alterations.

• Ensure that policy implementations are precise, compliant, and operationally efficient before production rollout.

• Track implementation results and pinpoint opportunities for ongoing improvement.

• Guide analysts and other team members in medical policy interpretation, coding methodologies, and clinical best practices.

• Cultivate collaborative relationships across internal departments and with external vendors.

⛳️ Requirements

• Valid Registered Nurse (RN) license in good standing.

• Bachelor’s degree in Nursing (BSN) is required; a Master's degree in Nursing, Healthcare Administration, Public Health, or a related field is preferred.

• A minimum of 5–7 years of progressive clinical nursing experience in an acute care, specialty care, or other complex healthcare environments.

• At least 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, National Correct Coding Initiative (NCCI), CMS payment methodologies, medical necessity criteria, and evidence-based clinical practice.

• Experience in supporting or implementing claims systems, configuration, or healthcare technology solutions.

• Strong analytical, problem-solving, project management, and communication skills.

🏝️ Benefits

• Health insurance.

• Paid time off.

• Flexible work arrangements.