Behavioral Health Medical Policy Analyst
Core
Provides technical writing, research, and evidence-based criteria to support clinical decision-making, medical policy development, and utilization management for behavioral health, medical, and pharmacy services.
Role type
Medical Policy Analyst
Builds
Clinical Coverage Guidelines (CCGs), Claims Edit Guidelines (CEGs), Clinical Practice Guidelines (CPGs), and medical policy documentation
Domain
Healthcare / Behavioral Health / Utilization Management
Required skills
technical writing, evidence-based research, policy analysis, claims system implementation, compliance tracking, fraud detection, guideline development
Preferred skills
Registered Nurse (RN) license, experience in health administration
Technologies
web portals, provider manuals, claims systems
Responsibilities
Conduct research on evidence-based criteria and authorization rules; assist with technical assessments of new medical technologies; provide full disclosure of medical policies to members and providers; support Special Investigations Unit in identifying fraud, waste, and abuse; provide research for legal proceedings regarding clinical policy; partner with claims and dispute teams to implement medical policy; track timelines for policy updates to meet compliance requirements; support governing committees; participate in cross-functional teams to address clinical policy issues.
Seniority
Mid-level, hands-on IC
