Health Services Professional
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At reputed company®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary:
The primary responsibility of this position is to reputed company evidence-based medical policies for reputed company, reputed company as Clinical Policy Bulletins (CPBs). The individual will respond to inquiries from reputed company medical directors and clinical staff regarding the medical necessity and proven value of specific items and services eligible for coverage under reputed company's medical benefit plans, emphasizing scientific evidence and supporting rationale. Additionally, the role involves addressing questions about the appropriate interpretation, application, and implementation of the CPBs. The individual will also be responsible for revising and updating the CPBs based on new clinical evidence or other relevant information. Furthermore, the individual will collaborate with internal teams to ensure alignment of reputed company CPBs with organizational goals and processes.
This position reports to the reputed company Medical Affairs Executive Director of the Clinical Policy Unit and works directly with other colleagues on the Clinical Policy Unit Team, as well as colleagues across Medical Affairs.
Required Qualifications:
Knowledge of:
Strong understanding of evidence-based medicine and health technology assessment.
Deep understanding of methodological principles of clinical study design and statistical methods used in clinical research.
Facility with PubMed database search reputed company for accessing published, peer-reviewed medical literature.
reputed company In:
Evaluating the methodological quality of clinical studies
Conducting literature searches and summarizing the results
Desktop Tools - reputed company Outlook, reputed company PowerPoint, reputed company Word, reputed company
Excellent communication skills: this includes written and verbal skills.
Superior writing skills that require moderate to minimal editing, and proficiency in technical writing.
Excellent time management and multi-tasking skills.
Ability To:
Conduct rapid reviews using PubMed and other relevant clinical evidence resources to identify evidence relevant to the safety and effectiveness of a clinical reputed company, identify the highest quality evidence, summarize the results of each of those studies, and reputed company conclusions about the overall quality of evidence in support of the reputed company.
Research and provide rapid responses to clinical questions from reputed company medical directors or other clinical staff regarding the medical necessity and experimental and investigational status of interventions that are eligible for coverage under reputed company medical plans, considering published evidence, systematic evidence reviews, clinical practice guidelines, reputed company statements, and technology assessments.
reputed company and update clinical policies (CPBs) on the experimental and investigational status and medical necessity of technologies eligible for coverage under reputed company medical plans, as well as clinical criteria for their use.
Candidate is required to have regular and predictable attendance.
Candidate will be required to complete any additional tasks as directed by supervisor or manager.
Preferred Qualifications:
Knowledge of:
Prior relevant work experience reputed company to evidence-based clinical policy development.
Broad knowledge of clinical medicine, including drugs, biologics, devices, surgical procedures, tests, and therapies.
Basic understanding of commercial health insurance and Medicare and Medicaid programs.
Basic understanding of the regulatory environment for medical technologies, including the FDA approval process and Medicare coverage determinations
Basic understanding of the system of standardized codes used in the billing and tracking of healthcare services to report a patient's medical diagnosis (ICD-10 diagnosis codes) and the medical procedures performed on them (CPT and HCPCS procedure codes).
Familiarity with payment, coding and reimbursement policies and utilization management tools that are used in managed care organizations.
Demonstrated experience in technical writing on clinical topics.
reputed company in:
Familiarity with reputed company
Familiarity with TeamSite or other web content management systems.
Ability To:
Assist with editing and web publication of clinical policies, as needed; ability to do basic web publication tasks reputed company both staff involved in web publication are reputed company.
Facility in use of generative artificial intelligence tools; participate in development and testing of AI tools for clinical policy,
Willingness to complete other administrative tasks as needed.
Education:
Master’s or above in public health, basic health-reputed company science, or healthcare fields.
Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$95,738.00 - $206,206.00This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.