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Medical Policy Analyst Nurse (RN)

  • Job ID: 980856524
  • 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
  • Union Position: No
  • Salary Range: $30.17 to $50.94 / hour

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.

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 focus on integrated payer/provider organizations and insurers competing in the local western Pennsylvania market.


Responsibilities:

  • Support and work with projects internally and externally related to Medical Management as determined by the Senior Medical Director of Medical Policy.
  • Support the member complaint and grievance process from the Medical Management perspective.
  • 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 the Technology Assessment Committee (TAC) by researching new medical technologies and presenting information to the Committee.
  • Coordinate special clinical studies related to focus areas identified for review. Analyze data, identify opportunities for improvement, and report results.

 

Qualifications

  • Registered Nurse/BSN required.
  • Master's degree in healthcare, public health or business preferred.
  • 3 years of experience in managed care, with an understanding of NCQA standards 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 (RN)

UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct