Clinical Policy Specialist

Job Summary:

The Clinical Policy Specialist I provides clinical policy support to both new and established lines of business (LOB) through managing state submissions, submitting Communication Request Forms, tracking processes, and ensuring clinical policy compliance.

Essential Functions:

• Assist Clinical Policy Project Specialist to execute, monitor and support new lines of business throughout the entire clinical policy project lifecycle.
• Audit, monitor and prepare clinical policies for NQCA, state, and internal audits
• Develop, implement, configure, and maintain decision trees, workflows, documentation and monitoring protocols to operationalize clinical policies and criteria in a timely manner
• Participate in department initiatives and projects including implementation of new document management systems
• Support the development and maintenance of enterprise Clinical Policy programs (i.e., policy assessments, department newsletter, network notification communications)
• Collaborate with interdisciplinary team members to achieve team goals
• Participate in risk assessment and continuous improvement activities, as needed
• Follow Workfront procedures to coordinate and implement changes ensuring regulatory, compliance, and business goals are met
• Ensure timely submission, accurate documentation, and tracking of all Communication Request Forms and network notifications for clinical policies to be published on external websites
• Monitor the CareSource public website to ensure policies are accurately published and accessible
• Document and track state submissions and approvals, keeping consistent communication with Clinical Policy team, leadership, and regulatory as necessary.
• Track and trend clinical policy metrics (i.e., CRF, archives, revisions) reported monthly, quarterly, end of year, and as needed
• Assist with Policy Tech functions to streamline policies through the entire end-to-end process
• Support the operational processes of the Clinical Policy Governance Committee (CPGC)
• Create agendas, document, and store minutes and pertinent records for all assigned team meetings as necessary
• Maintain and update job related internal policies and procedures applicable to Clinical Policy process and workflows
• Provide coverage for both Policy Coordinator and Policy Project Specialist when needed
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree or equivalent years of relevant work experience is required
• Health plan experience is preferred
• SharePoint management experience preferred
• Minimum of two (2) years of healthcare policy experience is preferred
• Documentation Management system experience is preferred

Competencies, Knowledge and Skills:

• Computer skills/proficiency level with Microsoft Word, Excel, search engines, and bibliographic software
• Detail-oriented and critical thinker
• Proficient in documentation management systems
• Proficient in SharePoint
• Proficient in creating and delivering effective PowerPoint presentations
• Knowledge of medical terminology, pharmacy claims processing, and healthcare administration
• Ability to interpret clinical information
• Excellent verbal and written communications skills
• Presentation and decision-making skills 
• Excellent organization and tracking skills
• Strong problem-solving skills
• Ability to communicate effectively with employees at all levels of the organization.
• Ability to work autonomously and in a team environment
• Ability to handle multiple priorities/projects simultaneously

Licensure and Certification:

• Basic Six Sigma or Lean certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel may be required to fulfill job duties

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business