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

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.