Job Description

The Medical Policy and Programs position develops and manages medical criteria while ensuring accurate and consistent application of clinical policies. Supervises and audits medical management compliance with state and/or federal agencies, regulatory entities, accreditation standards, corrective action plans, and delegate entities with integration across business units.


Primary Responsibilities:

  • Develops, updates, and investigates the need for medical criteria, policies, and procedures using appropriate clinical resources to support medical management functions.
  • Supports implementation and staff development related to evidence-based clinical decision-making. Consults with physicians, other clinicians, and staff to ensure appropriate compliance, accuracy, and inter-rater reliability of clinical decision-making.
  • Serves as as key contributor and leads staff training on medical management principles, programs and deliverables while managing related policies and procedures. Serves as the medical management liaison with Quality, Compliance, and other business partners with a focus on quality improvement projects.
  • Ensures medical management meets accreditation standard in addition to state, federal and any other regulatory requirements are met for audit readiness.
  • Provides support as a clinical subject matter expert for internal and/or external audits; supervises coordination and performance of all oversight activities.
  • Develops audit tools and compiles results to identify quality improvement opportunities and implements necessary changes.
  • Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision and values of the organization.

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and management care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.


Equal Opportunity Employer Minorities/Women/Veterans/Disabled



  • Bachelor's degree, current unrestricted RN license, or equivalent work experience in lieu of degree required.
  • Minimum seven (7) years of clinical practice experience
  • Minimum two (2) years of utilization management, care management or case management experience in a health plan setting
  • Working knowledge and solid understanding of accreditation standard and State and Federal insurance legislation
  • Strong analytic skill with the ability to draw conclusion and translate complicated data into useable information.
  • High tolerance for complex, ambiguous and shifting environments, including a matrix management structure
  • Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problems
  • Demonstrated organizational and project management skills to manage complex projects through effective planning, tracking and resources allocation to meet business objective and timelines.
  • Proficiency with Microsoft office applications; type a minimum of 35 wpm on a computer keyboard
  • Excellent verbal, written and interpersonal communication skills with the ability to build consensus
  • Ability to process map and manage large projects to successful completion

Application Instructions

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