To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by developing and maintaining Medical Policies that define medical necessity under Health First benefit plans. The position creates value by maximizing operational effectiveness in the Utilization Management area, ensuring consistent and appropriate decision-making and minimizing legal risk. Medical Policy Administration involves the analysis of health data, clinical research, cost-effectiveness, and health policy, with the development of professional written Policies and other communication tools. Generally works under specific deadlines and frequently handles multiple complex projects, operating with minimal supervision.

Primary Accountabilities:

• Adhering to and enforcing all corporate safety initiatives 
• Overseeing the development, implementation and maintenance of operational Policies and Procedures 
• Ensuring that Medical Policies consider patient safety 
• Developing high-quality Medical Policies and associated documents based on evidence, taking into account clinical research, data analysis, best-practices, the synthesis of available information. Presents research and recommendations to internal teams and Physician Advisory Committee. 
• Ensuring that processes related to Medical Policies comply with state and federal regulations and quality accreditation standards 
• Implementing Medical Policies in accordance with product line contract requirements, working with the system configuration team as needed.
• Consults with applicable industry resources, regulatory authorities and health plan administrators to facilitate the development and maintenance of applicable Medical Policies 
• Ensures professional product is comprehensive and accurately reflects local medical practice 
• Monitors and reports on industry developments which may impact applicable medical services offerings including legislative/legal developments at the local, state and federal level 
• Interacts with internal teams as needed to ensure that medical policies accurately address current workflow processes and operations ? Interacts extensively with medical directors and health plan clinicians regarding Medical Policies 
• Utilizes health plan resources in determining accurate diagnosis and procedure coding for appropriate policy development