Sr Clinical Policy Analyst

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

Minimum Qualifications:

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

Preferred Qualifications:

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470

All Other Locations (within approved locations): $71,600 - $106,505

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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