Description and Requirements

The Sr Clinical Policy Analyst is responsible for promoting compliance and regulatory requirements within Healthfirst's Clinical areas. The role supports several organizational governance committees, assists the Healthfirst Medical Directors and Utilization Management business units and aids with the development and oversight of clinical/medical policies. The position plays a key role in the development of new processes related to these committees and facilitates improved regulatory compliance within the Clinical department.

Duties/Responsibilities:

• Support the Medical Policy and Clinical Utilization Management (UM) Governance Committee Chairs, committee members, and related workgroups by organizing all meeting materials (e.g. meeting minutes, presentations, etc.), tracking follow-up activities, and preparing/maintaining related reports and documentation.
• Facilitate the Healthfirst medical and clinical policy processes, including developing new policies, monitoring industry policy trends and tracking annual policy renewals/approvals.
• Collaborate on policy reviews with committee stakeholders and clinical business unit stakeholders
• Engage with, support and spearhead the policy work that will inform Medical and Clinical strategy
• Perform editorial formatting and review of policies, confirm policy references, and obtain necessary approvals from key governance committee members.
• Review the appropriate UM or related clinical and medical policies, job aids/procedures, and correspondence and make recommendations for policy creation/revision and/or committee action
• Ensure parity in processes across clinical and medical departments
• Conduct ad hoc medical condition research per Medical Director and/or UM Clinical Director requests.
• Collaborate with the Regulatory, Compliance, Legal and Clinical departments to ensure deliverables adhere to local, state, federal, and Healthfirst-specific compliance and regulatory guidelines.
• Monitor any Corrective Action Plans (CAPs) and related committee/workgroup activities through to completion
• Identify potential organizational risks and help facilitate process improvements
• Support accreditation submissions, regulatory surveys, and internal audits
• Ensure timely and accurate responses to any requests for information or audits.
• Build sustainable relationships of trust through open and interactive communication with cross-functional teams at all levels within Healthfirst.
• Comply with HIPAA requirements and maintain Protected Health Information (PHI) confidentiality of member, provider, medical and departmental information.

• Additional duties as assigned

• Associate's degree from an accredited institution
• Registered Nurse (RN), Licensed Social Worker (LCSW or LMSW)
• Work experience using and interpreting medical terminology and concepts
• Knowledge of Centers for Medicare and Medicaid Services (CMS) and/or New York State Department of Health (NYSDOH) regulations
• Previous regulatory/compliance experience within a managed care environment
• Experience with Clinical guidelines including but not limited to Milliman Care Guidelines, Hayes Clinical Guidelines, Encoder Pro, EMEDNY,CMS National and Local Coverage Determinations

• Bachelor's degree
• Knowledge of compliance and regulatory guidance/regulations across the Medicaid, Medicare, MLTCPs, and Commercial Lines of Business.
• Experience working in a fast-paced environment that requires flexibility and adapting to change while managing multiple priorities simultaneously.
• Work experience requiring strong verbal and effective written communications while demonstrating exceptional grammar and spelling skills.
• Experience presenting and communicating to cross-functional groups within an organization
• Problem-solving, initiative taking, multitasking and critical thinking skills
• Experience with MS Office Suite, MS Teams, MS Outlook, SharePoint, Logic Manager, and Adobe Acrobat.