Job Description

Job Title: Medical Policy Analyst Nurse (RN)
Job ID: 683076
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Medical Director Service
Location: 600 Grant St, Pittsburgh PA 15219

Description

Are you a nurse experienced in managed care, and interested in data-driven continuous quality improvement? Do you see yourself as an agent for change? Are you interested in an opportunity where you can use your critical thinking abilities? UPMC Health Plan may have an opportunity for you!

UPMC Health Plan is hiring a Full-Time Medical Policy Analyst RN to help support the Medical Director Service Department for its Downtown location.

This position will work Monday through Friday daylight hours, and offers flexible scheduling.

The primary role of the Medical Policy Analyst RN is to support the Medical Policy Department in developing and communicating coverage policies for healthcare services covered by UPMC HealthPlan, ensuring the policies reflect the most current medical evidence of effectiveness and patient safety, and meet the myriad federal and state regulatory requirements including CMS, PID, DHS, and NCQA.

The Medical Policy Analyst position requires a high-energy, detail oriented individual interested in and knowledgeable about health- and public- policy and medically necessary clinical services requested of commercial insurers, third-party administrators and Medicaid and Medicare managed care organizations.

The Analyst will engage in a full range of policy and advocacy activities through research, writing, collaboration with multiple stakeholders (including UPMC providers and other departments of the HealthPlan), and other substantive and operational activities.

The Analyst will perform comprehensive review of the published medical evidence on medical interventions, as well as coverage policies and utilization management standards of national insurers, accountable care organizations, with particular focus on integrated payer/provider organizations and insurers competing in the local western Pennsylvania market.

Responsibilities:
  • Coordinate special clinical studies related to focus areas identified for review. Analyze data, identify opportunities for improvement, and report results.
  • Develop and maintain Medical and Pay Policies (HealthPlan coverage policies). Ensure that the policies reflect the most current medical evidence of effectiveness and patient safety, meet regulatory requirements, and reflect NCQA and AHRQ standards.
  • Submit TAC recommendations to the Benefits and Reimbursement Committee.
  • Support and work with projects internally and externally related to Medical Management as determined by the Senior Medical Director of Medical Policy.
  • Support the Technology Assessment Committee (TAC) by researching new medical technologies and presenting information to the Committee.
  • Support the member complaint and grievance process from the Medical Management perspective.

Qualifications

  • 3 years of experience in managed care with an understanding of NCQA standards preferred.
  • BSN required
  • Master's degree preferred
  • Ability to prioritize multiple projects and meet expected deadlines required. 
  • Excellent verbal and written communication and interpersonal skills required. 
  • Ability to interpret data/information, recognize trends and identify appropriate goals required.

Licensure, Certifications, and Clearances:
  • Registered Nurse/BSN required. 
  • Master's degree in healthcare, public health or business preferred

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.37 to $47.88

Union Position: No

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

QUALITY & SAFETY
DIGNITY & RESPECT
CARING & LISTENING
RESPONSIBILITY & INTEGRITY
EXCELLENCE & INNOVATION

UPMC provides a total rewards package that can help you achieve the goals you have for your career and your personal life. Whether you want to learn a new skill through a training course, reach personal health and wellness targets, become more involved in your community, or follow a career path that provides you with the right experience to be successful, UPMC can help you get to where you want to be.



Now more than ever, YOU can help us shape our communities and UPMC into a better place for everyone to work, study, play, and thrive.

Learn more about working here and check out our policies and recent updates.

Share:
Talent Network