Company : Highmark Inc.Job Description : JOB SUMMARY This pivotal role drives the full lifecycle of medical policies, from initial development and evidence-based criteria writing to publication, maintenance, and assisting with impact assessment through data analysis. The incumbent will act as a primary owner of assigned medical policies, ensuring their accuracy, clinical soundness, and operational feasibility. A core responsibility of this position is to leverage advanced data analytics to generate critical insights, identify actionable opportunities, and develop sophisticated reporting solutions. These data-driven contributions will directly inform and influence medical policy decisions, ensuring alignment with the Quadruple Aim of Healthcare: lower per capita health care costs, improved outcomes and quality of care received, and optimal member/patient and provider experiences with care delivery. The incumbent will also act as a clinical lead and expert on various workgroups, ensuring policies are grounded in strong clinical evidence and operational realities.

• Full-Cycle Medical Policy Ownership: Own the development, revision, and maintenance of a portfolio of commercial medical policies, encompassing both internally developed and vendor-sourced criteria. This includes proactive monitoring, review, and timely updates in response to new evidence, regulatory changes, or escalated inquiries.
• Evidence-Based Clinical Criteria Writing: Research, analyze, and synthesize clinical literature, professional society guidelines, and internal data to develop clear, concise, and evidence-based medical necessity criteria for assigned policies.
• Data-Driven Policy Development & Influence: Utilize robust, data-driven insights from complex healthcare datasets (e.g., claims, clinical, utilization, pharmaceutical) to inform policy development, identify areas for improvement, and assist in quantify the potential impact of policy changes on clinical outcomes, cost, and member experience.
• Operational Integration & Coding: Engage non-clinical teams to ensure operational guidelines are aligned with clinical policy intent. Develop and maintain a thorough understanding of medical coding (ICD-10, CPT, HCPCS) and ensure accurate coding principles are incorporated into policy criteria.
• Policy Publication & Quality Assurance: Manage the full publication process for assigned policies. Conduct peer reviews of other policies as part of the quality assurance process to ensure accuracy, clarity, and consistency.
• Consultative & Expert Role: Serve as a clinical lead/expert on various workgroups and sub-committees, providing clinical and data-driven insights. Act as a subject matter and technical expert for internal and external customers, articulating analytic findings, business implications, and recommendations.
• Stakeholder Liaison: Serve as a key liaison between the Medical Policy department, other internal departments (e.g., Operations, Provider Relations, Clinical Programs), and external vendors to ensure seamless policy implementation and understanding.
• Mentorship & Training: Train and orient new staff to the department and policy development/review procedures. Mentor new team members on best practices in policy writing, research, and data application.
• Complex Data Analysis: Conduct statistical analysis on large and complex healthcare datasets, identifying significant patterns, correlations, and causal relationships relevant to medical policy decisions and impact assessment.
• Communication & Presentation: Effectively translate complex clinical and analytical findings into clear, concise, and compelling presentations and reports for diverse audiences, including clinical professionals, executive leadership, and operational partners. ESSENTIAL RESPONSIBILITIES
• Leads the design, development, execution, dissemination and interpretation of clinical and population health analyses, metrics and reports using clinical, member, financial and administrative data to identify, develop and/or monitor actionable opportunities for improving health and healthcare outcomes and clinical quality and costs of care, efficiently and effectively managing projects to successful completion.
• Establishes strong, collaborative and effective relationships and communication with internal and external clinical, administrative, operational, financial and technical stakeholders to ensure analytics are actionable and aligned with organizational strategic priorities, needs, plans and resources.
• Serves as a strategic business partner to internal and external stakeholders as demonstrated by providing thought leadership and subject matter expertise, and by anticipating and actively proposing, designing and executing analyses.
• Provides consultative, technical, subject matter and business expertise mentorship to colleagues across the enterprise.
• Other duties as assigned or requested. EDUCATION Required
• Master's Degree in Public Health, Nursing, Econom