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UPMC Health Plan is hiring a full-time Medical Policy Analyst RN to join the Medical Director Services team! While the team 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 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 particular 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.

+ BSN required. Advanced degree is preferred.

+ Prior experience with utilization management and/or case management is strongly preferred.

+ Proficient with Microsoft Office Products preferred.

+ 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 and BSN required.

+ Act 34

*Current 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 current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran