Providence Health & Services Medical Policy Research Analyst in California
Providence St. Joseph Health is calling a Medical Policy Research Analyst based out of our location in Beaverton, OR. This role is remote and can reside in the footprint of Providence in the states of AK, WA, OR, CA, MT, NM and TX.
We are seeking a Medical Policy Research Analyst who will responsible for the identification, appraisal, and summary of scientific literature, clinical practice guidelines, and state and federal health policy for the development and implementation of Providence Health Plan (PHP) & Providence Health Assurance (PHA) medical policies which serve as the basis of coverage decisions by internal clinical staff and external providers. Primary responsibilities include critical evaluation of the current peer-reviewed scientific evidence to assess the relative safety and efficacy of medical devices, procedures, services and laboratory testing. This position synthesizes findings from evidence assessments, clinical practice guidelines, Medical Director feedback, contracts, benefits and plan summaries to draft and review medical policy criteria to ensure all medical policies are evidence-based, administrable, and meet all regulatory, accreditation and contractual requirements for all departments and lines of business at Providence Health Plans. The medical policy research analyst provides policy recommendations based on concise assessment summaries which highlight findings for consideration and approval at Medical Policy Committee and New Technology Assessment Committee meetings. This position works closely with Coding Compliance, Systems Administration, Service Operations and Product & Marketing to ensure proper coding edits are applied to all medical policies. The medical policy research analyst will also engage with medical directors, reimbursement specialists and other key stakeholders to vet policy issues and provide in-service trainings as needed. In addition, this position is responsible for data analysis to support policy recommendations.
In this position you will have the following responsibilities:
Responsible for developing, writing, and updating medical policies in a timely fashion to meet compliance deadlines.
Assess new and existing technologies through critical appraisal of the current evidence-based literature, clinical practice guidelines, and best practices as they relate to utilization management.
Work closely with PHP Medical Directors to formulate and recommend medical policy criteria, which is consistent with the current scientific evidence and standards of care.
Investigate and consider member benefits, provider network contracts, regulatory and compliance requirements and claims and medical management systems configuration to assure policies can be administered in-line with these business areas.
Analyze and interpret utilization data to inform decisions regarding utilization management initiatives and related cost savings.
Prepare and present evidence-based assessment summaries on specific health care service topics to inform business decisions.
Support integration of medical and new technology policies throughout PHP (may include in-service teachings, code reconciliation, etc.).
Participate in medical policy and new technology committee meetings to present medical policy drafts, key findings and recommendations.
Review relevant codes and related Change Request Forms as necessary to ensure policies are in-line with code edits.
Document all research processes and medical policy decisions.
Assist in workload distribution of the team and may represent the medical policy team at various internal and external meetings, if applicable.
Actively participates in and contributes to team meetings, efficiency efforts, process improvements, group well-being and cohesion.
Required qualifications for this position include:
Master's Degree in Health science related field (e.g. Nursing, Pharmacy, Public Health, Epidemiology, Biostatistics, Genetics) -OR- Current licensure or professional certification (e.g., RN or PA).
3 years Clinical or research experience.
2 years Experience developing and drafting medical policies and assessing medical technologies.
Experience in collecting, critically evaluating, and summarizing information from the available scientific literature, clinical practice guidelines, and other relevant source
Preferred qualifications for this position include:
Health plan experience.
Medical coding experience.
About Providence in Oregon.
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Research
Other Location(s): Montana, California, New Mexico, Oregon, Washington, Texas, Alaska
Req ID: 317585