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 stakeholdersEngage with, support and spearhead the policy work that will inform Medical and Clinical strategyPerform 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 actionEnsure parity in processes across clinical and medical departmentsConduct 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 completionIdentify potential organizational risks and help facilitate process improvementsSupport accreditation submissions, regulatory surveys, and internal auditsEnsure 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 institutionRegistered Nurse (RN), Licensed Social Worker (LCSW or LMSW)  Work experience using and interpreting medical terminology and conceptsKnowledge of Centers for Medicare and Medicaid Services (CMS) and/or New York State Department of Health (NYSDOH) regulationsPrevious regulatory/compliance experience within a managed care environmentExperience 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 degreeKnowledge 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 organizationProblem-solving, initiative taking, multitasking and critical thinking skillsExperience with MS Office Suite, MS Teams, MS Outlook, SharePoint, Logic Manager, and Adobe Acrobat.

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.