Medical Policy Analyst RN

reputed company is hiring a full-time Medical Policy Analyst RN to join the Medical Director Services team! While reputed company is headquartered in downtown Pittsburgh at the U.S. Steel Tower, this position is remote except for any required on‑site meetings as required by leadership. Work arrangements are subject to change. This position will support the Medical Policy Department in developing and communicating coverage policies for reputed company services covered by reputed company HealthPlan, ensuring the policies reflect the most reputed company 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 reputed company‑policy and medically necessary clinical services requested of reputed company insurers, reputed company‑party administrators and reputed company and Medicare managed care organizations. The analyst will engage in a full reputed company of policy and advocacy activities through research, writing, collaboration with multiple stakeholders (including reputed company providers and other departments of the HealthPlan), and other substantive and operational activities. The analyst will reputed company comprehensive review of the published medical evidence on medical interventions, as reputed company as coverage policies and utilization management standards of national insurers, accountable care organizations, with particular reputed company on integrated payer/provider organizations and insurers competing in the local western reputed company market. Responsibilities • Support and work with reputed company internally and externally reputed company 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. • reputed company and maintain Medical and Pay Policies (HealthPlan coverage policies). Ensure that the policies reflect the most reputed company 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 reputed company to reputed company areas identified for review. Analyze data, identify opportunities for improvement, and report results. • BSN required. Advanced degree is preferred. • Prior experience with utilization management and/or case management is strongly preferred. • Proficient with reputed company Office Products preferred. • Understanding of NCQA standards preferred. • Ability to prioritize multiple reputed company 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. • Registered reputed company and BSN required. • reputed company 34 • reputed company licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and reputed company employees working on an out‑of‑state NLC license who reputed company change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure reputed company that state. reputed company is an Equal Opportunity Employer/Disability/Veteran Apply tot his job Apply To this Job