This position is 100% remote. Candidates must be based in Maryland, Washington, DC, Virginia, or West Virginia.
Overview & Responsibilities
We are seeking a Medical Policy Analyst to join a dynamic team within a leading health insurance provider. This role involves supporting the development, coordination, and distribution of medical policies to ensure compliance with state mandates and corporate standards. The ideal candidate will possess strong research and analytical skills, along with the ability to interpret state laws and mandates to align with company policies. Key responsibilities include :
Performs in-depth research on topics identified as actual or potential medical policies.
Evaluates current peer-reviewed articles and other literature to determine its appropriateness for support of and inclusion in policies.
Assesses and communicates impact of information on company business or medical policy.
Writes evidenced-based medical policies / operating procedures in relation to legislative mandates, new technology assessments, contractual provisions, corporate philosophy, and accepted standards of medical practice in order for them to be applied uniformly and consistently by across all lines of business.
Maintains the Medical Policy Reference Manual (MPRM) including resource files and publications.
Ensures dissemination of policies and procedures to and from the Medical Policy Implementation Team and to other appropriate departments.
Ensures maintenance and accuracy of the on-line versions of the MPRM, as well as respond to questions from business units throughout the organization providing written clarification of existing policies, new policy development, emerging studies, trends and other interest related to medical policy guidelines.
Supports policy updates and revisions for compliance, with approximately 3 to 5 policies reviewed monthly.
Prepares and presents policy updates / recommendations to internal committees for approval.
Collaborates closely with Claims and Configurations teams to ensure policy changes are implemented effectively
Assists in the annual review and update of approximately 400 active medical policies in compliance with Maryland state regulations.
Utilizes tools and systems such as UpToDate, Hayes, Milliman Care Guidelines (MCG), and EncoderPro for policy research and coding support.
Maintains and organizes policy documentation and workflows within SharePoint.
Required Skills & Experience
Possess Registered Nurse (RN) licensure – Maryland State and / or compact State Licensure.
Experience in researching and interpreting healthcare regulations, mandates, and policies.
Familiarity with state healthcare laws and their application in policy development.
Knowledgeable of CPT and ICD-10 coding systems.
Proficiency in Microsoft Excel for data analysis and policy tracking.
Strong critical thinking and analytical skills.
Strong organizational and project management skills.
Excellent written and verbal communication skills.
Preferred Skills & Experience
Certified Professional Coder (CPC) or other coding certification.
Experience with SharePoint for document management and collaboration.
Experience using EncoderPro and other coding resources.
Knowledge and experience with UpToDate, Hayes, and Milliman Care Guidelines (MCG).
Prior experience in a health insurance or healthcare policy environment.
Background in managing or supporting compliance-driven projects.
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