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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This pivotal role drives the full lifecycle of medical policies, from initial development and evidence-based criteria writing to publication, maintenance, and assisting with impact assessment through data analysis. The incumbent will act as a primary owner of assigned medical policies, ensuring their accuracy, clinical soundness, and operational feasibility. A core responsibility of this position is to leverage advanced data analytics to generate critical insights, identify actionable opportunities, and develop sophisticated reporting solutions. These data-driven contributions will directly inform and influence medical policy decisions, ensuring alignment with the Quadruple Aim of Healthcare: lower per capita health care costs, improved outcomes and quality of care received, and optimal member/patient and provider experiences with care delivery. The incumbent will also act as a clinical lead and expert on various workgroups, ensuring policies are grounded in strong clinical evidence and operational realities.

+ **Full-Cycle Medical Policy Ownership:** Own the development, revision, and maintenance of a portfolio of commercial medical policies, encompassing both internally developed and vendor-sourced criteria. This includes proactive monitoring, review, and timely updates in response to new evidence, regulatory changes, or escalated inquiries.

+ **Evidence-Based Clinical Criteria Writing:** Research, analyze, and synthesize clinical literature, professional society guidelines, and internal data to develop clear, concise, and evidence-based medical necessity criteria for assigned policies.

+ **Data-Driven Policy Development & Influence:** Utilize robust, data-driven insights from complex healthcare datasets (e.g., claims, clinical, utilization, pharmaceutical) to inform policy development, identify areas for improvement, and assist in quantify the potential impact of policy changes on clinical outcomes, cost, and member experience.

+ **Operational Integration & Coding:** Engage non-clinical teams to ensure operational guidelines are aligned with clinical policy intent. Develop and maintain a thorough understanding of medical coding (ICD-10, CPT, HCPCS) and ensure accurate coding principles are incorporated into policy criteria.

+ **Policy Publication & Quality Assurance:** Manage the full publication process for assigned policies. Conduct peer reviews of other policies as part of the quality assurance process to ensure accuracy, clarity, and consistency.

+ **Consultative & Expert Role:** Serve as a clinical lead/expert on various workgroups and sub-committees, providing clinical and data-driven insights. Act as a subject matter and technical expert for internal and external customers, articulating analytic findings, business implications, and recommendations.

+ **Stakeholder Liaison:** Serve as a key liaison between the Medical Policy department, other internal departments (e.g., Operations, Provider Relations, Clinical Programs), and external vendors to ensure seamless policy implementation and understanding.

+ **Mentorship & Training:** Train and orient new staff to the department and policy development/review procedures. Mentor new team members on best practices in policy writing, research, and data application.

+ **Complex Data Analysis:** Conduct statistical analysis on large and complex healthcare datasets, identifying significant patterns, correlations, and causal relationships relevant to medical policy decisions and impact assessment.

+ **Communication & Presentation:** Effectively translate complex clinical and analytical findings into clear, concise, and compelling presentations and reports for diverse audiences, including clinical professionals, executive leadership, and operational partners.

ESSENTIAL RESPONSIBILITIES

+ Leads the design, development, execution, dissemination and interpretation of clinical and population health analyses, metrics and reports using clinical, member, financial and administrative data to identify, develop and/or monitor actionable opportunities for improving health and healthcare outcomes and clinical quality and costs of care, efficiently and effectively managing projects to successful completion.

+ Establishes strong, collaborative and effective relationships and communication with internal and external clinical, administrative, operational, financial and technical stakeholders to ensure analytics are actionable and aligned with organizational strategic priorities, needs, plans and resources.

+ Serves as a strategic business partner to internal and external stakeholders as demonstrated by providing thought leadership and subject matter expertise, and by anticipating and actively proposing, designing and executing analyses.

+ Provides consultative, technical, subject matter and business expertise mentorship to colleagues across the enterprise.

+ Other duties as assigned or requested.

EDUCATION

Required

+ Master's Degree in Public Health, Nursing, Economics, Health Sciences, Informatics, Biostatistics, Statistics, Epidemiology or Pharmacy or related field

Substitutions

+ Bachelor’s Degree in Public Health, Nursing, Economics, Health Sciences, Informatics, Biostatistics, Statistics, Epidemiology, Pharmacy **OR** related field with 2 years of relevant work experience in lieu of a Master’s Degree OR 8 years of relevant work experience

Preferred

+ Doctorate in Medicine, Public Health, Nursing, Economics, Health Sciences, Informatics, Biostatistics, Statistics, Epidemiology, Pharmacy or related field

EXPERIENCE

Required

+ 7 years of leading the design, execution and dissemination of clinical and population health reporting, analyses and studies of progressive scope and complexity

+ 7 years with coding languages, analytical software, systems, tools and processes using claims, clinical, enrollment and provider data

+ 5 years of project leadership in a complex, matrixed environment (payer and/or provider preferred)

+ 5 years of providing analytical consultation to clinical, administrative, operational and financial stakeholders

Preferred

+ Experience with medical policy and utilization management functions

+ Medical coding experience

LICENSES or CERTIFICATIONS

Required

+ None

Preferred

+ Medical coding certificate (AAPC)

SKILLS

+ Demonstrated record of data-driven discovery, intense intellectual curiosity, and a passion for working with data to answer important questions about clinical care and population health that drive the Quadruple Aim

+ Strong working knowledge of coding languages, relational databases, quantitative and qualitative analytic methodologies, advanced analytics and statistics

+ Excellent communication and facilitation skills with project team members, stakeholders, executives, and external customer, exceptional written and oral presentation skills, proven ability to communicate interpersonallly and technically with technical and non-technical, and internal and externbal audiences, and the ability to lead through influence

+ Healthcare industry expertise and experience, knowledge about the shifting healthcare environment including trends concerning health insurance, healthcare delivery, provider relationships and regulatory issues

+ Sophisticated knowledge of how organizations work and how to get things done through formal and informal channels

+ Exhibition of perseverance through energy, drive and demonstrated success when resistance or setbacks are encountered

+ In-depth understanding of and experience with both clinical and business processes, and the ability to identify opportunities for improvement and develop solutions

+ Demonstrated ability to informally lead matrixed teams of technical, clinical, administrative, financial and operational staff to achieve shared organizational objectives and strategic goals

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._

**_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._

_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy._

_Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._

_ments._

Pay Range Minimum:

$78,900.00

Pay Range Maximum:

$147,500.00

_Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at [email protected]

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Req ID: J273990