Description and Requirements

The Senior Manager, Medical Policy is responsible for overseeing the development, implementation, and management of Healthfirst's medical policies and procedures. This role requires a strategic mindset with a deep understanding of clinical practices, managed care regulatory requirements, and industry standards. The Sr Mgr will ensure that Healthfirst medical policies will support effective, evidence-based policies that align with the organization's goals and regulatory obligations. The role drives several organizational governance committees, collaborates with Healthfirst Medical Directors and Utilization Management leadership, and works closely with Healthfirst's IT leadership in order to ensure meaningful implementation of policies.

• Develops, reviews, and updates medical policies and clinical guidelines to ensure they are evidence-based and aligned with best practices
• Collaborates with clinical experts and stakeholders to gather input and ensure policies reflect the latest advancements in medical science and technology
• Monitors changes in regulations, laws, and industry standards in order to maintain Healthfirst's regulatory and business position
• Leads the strategic process for medical and clinical policy development, including identifying and acting on opportunities for improvement or innovation and tracking annual policy renewals/approvals
• Assesses the impact of medical policies on the organization's operations and outcomes, and makes recommendations for adjustments as needed
• Analyzes aggregated medical and claims data to evaluate the effectiveness of policies and identify areas for improvement.
• Prepares and presents reports on policy performance, trends, and outcomes to senior management and other stakeholders
• Collaborates on policy reviews with committee stakeholders and clinical business unit stakeholders
• Ensures parity in processes across clinical and medical departments
• Conducts ad hoc medical condition research per Medical Director and/or UM Clinical Director requests
• Collaborates with the Regulatory, Compliance, Legal and Clinical departments to ensure deliverables adhere to local, state, federal, and Healthfirst-specific compliance and regulatory guidelines.
• Identifies potential organizational risks and helps facilitate process improvements
• Supports accreditation submissions, regulatory surveys, and internal audits
• Ensures timely and accurate responses to any requests for information or audits.
• Builds sustainable relationships of trust through open and interactive communication with cross-functional teams at all levels within Healthfirst.
• Complies with HIPAA requirements and maintains Protected Health Information (PHI) confidentiality of member, provider, medical and departmental information.

• Additional duties as assigned

• Graduate of Nurse Practitioner or Physician Assistant program with active and valid license
• 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 following the new developments in the published medical literature and practice guidelines, and synthesizing reports in response to clinical questions
• Experience with Clinical guidelines including but not limited to Milliman Care Guidelines, Hayes Clinical Guidelines, Encoder Pro, EMEDNY,CMS National and Local Coverage Determinations

• Doctorate Degree
• Graduate of an accredited medical school or similar clinical program
• 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.