Manager, Medical Policy

Graduate degree in Healthcare Administration, Public Health, Health Policy, Health Services Research, Epidemiology, or a closely related discipline (such as Nursing or another allied health field). 5–8 years in healthcare, with 3–5 years specifically focused on medical policy development, clinical research, or medical writing. Experience in people leadership, including the ability to manage, mentor, and develop clinical professionals. Proficiency in leveraging clinical databases (e.g., PubMed) to conduct literature reviews, evaluate evidence, and synthesize findings. Expert ability to interpret complex clinical data and conduct health technology assessments to determine medical coverage standards.

Lead the review of clinical literature, regulating agency guidance, and specialty society guidelines to develop coverage criteria. Conduct and manage health technology assessments for novel medical technologies. Coordinate with internal and external physicians for clinical review and validation of medical policies. Translate complex clinical data into precise medical necessity criteria and clinical positions. Own the end-to-end drafting and maintenance of the medical policy library. Prepare and present evidence-based medical policies and summaries of changes to committees. Oversee, onboard, develop, and manage a team of clinical FTEs and contractors. Ensure clinical policy development processes are streamlined and align with departmental strategy. Ensure clinical policy development processes and documentation comply with State, Federal, and NCQA requirements. Provide support on regulatory audits and quality accreditation surveys. Compliance with all applicable laws and regulations.