[Hiring] Corporate Medical Policy Analyst @Amerihealth Caritas

Role Description

The Corporate Medical Policy Analyst is responsible for researching, developing, and maintaining evidence-based clinical policies that promote consistent medical necessity determinations, support quality health outcomes, and ensure compliance with enterprise, Medicare, Medicaid, and ACA Exchange requirements on state and federal levels. The Analyst supports policy development by conducting comprehensive clinical research, competitor analysis, and peer review activities in response to requests from Medical Directors, Utilization Management, Compliance, Legal Affairs, the Clinical Policy Committee, Markets, and/or organizational leadership, as well as to address gaps in existing criteria or emerging standards of care. Working independently, the Analyst evaluates clinical literature, professional society guidelines, regulatory requirements, and industry best practices to develop clear, transparent, and defensible medical policies. The role collaborates with internal and external stakeholders and is responsible for presenting policy recommendations to the Clinical Policy Committee, providing evidence-based rationale for proposed policy decisions, and effectively addressing questions or concerns to support policy approval and governance.

Work Arrangement

• Monday through Friday, 8:30 AM EST to 5:00 PM EST
• Remote role

Responsibilities

• Annual updates to clinical policies:
  • Competitor and utilization analysis
  • Conduct literature review and evaluate clinical, regulatory, safety, FDA information and new evidence
  • Incorporate recommended revisions into current policy or assess for retirement vs. major change vs. no major change
  • Internal peer review
  • Presentation and defense of policy updates to Clinical Policy Committee
  • Preparation of policy for final publication
• New policy development:
  • Development of clinical policies for requested topics, emerging technologies, regulatory changes, and inventory gaps
  • Competitor and utilization analysis
  • Synthesize research, guidelines, technology assessments, FDA information, and payer positions
  • Internal peer review
  • Coordination with requester
  • Presentation and defense of new policy to Clinical Policy Committee
  • Preparation of policy for final publication
• Market and competitor analysis:
  • Compare Medicaid and commercial benchmark policies
  • Identify emerging topics and policy-development priorities
  • Analyze coverage criteria, exclusions, documentation requirements, and supporting evidence
  • Maintain dated, source-linked comparisons
• Clinical practice guideline research/review:
  • Identify new and revised clinical practice guidelines
  • Assess whether guideline changes require policy updates
  • Maintain guideline inventory, source links, review dates, and recommendation summaries
  • Prepare new document for CPC/QAPIC and publishing
• Vendor criteria review:
  • Review criteria and revisions from delegated UM vendors
  • Review for potential overlap or conflicts with internal clinical policies
  • Summarize changes and develop memos for QAPIC and other state approval committees
• Coding analysis:
  • Research current active CPT/HCPCs codes applicable to policies
  • Verify fee schedule status, coverage requirements, benefit limits, and authorization rules across the Enterprise
  • Identify and resolve policy, coding, claims, and authorization inconsistencies
  • Update policy code lists and code/policy crosswalk

Qualifications

• Bachelor's Degree required
• Master's Degree: MS/MSN or higher; health policy, public health, epidemiology or other clinical specialty preferred
• Physician Assistant/Advanced Practice Nurse/Pharmacist or other Master’s level clinical licensure preferred
• Minimum of 3 years of experience as an independent clinician
• Minimum of 3 years of experience researching and writing clinical policies, preferably for a payor
• Coding experience or Certified Professional Coder (CPC) preferred

Skills and Abilities

• Demonstrated well-developed technical/clinical writing skills; research experience with published works available for review
• Strong critical thinking and analytical skills, with the ability to evaluate and synthesize extensive clinical research, evidence-based literature, and regulatory guidance into concise, well-structured and defensible clinical policies
• Strong written, verbal, and presentation skills with the ability to analyze complex clinical information, develop clear and concise policy documentation, effectively present evidence-based recommendations to governance committees, and confidently articulate and defend policy decisions in response to stakeholder questions and concerns
• Demonstrates strong self-management and initiative, with the ability to work independently, manage competing priorities, and consistently deliver high-quality results with minimal supervision while proactively identifying and addressing issues and opportunities for improvement
• Proficient with MS Office and research databases such as Cochrane, Science Direct, etc. required

Benefits

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement and more