Medical Policy & Special Project Clinical Analyst – RN

🔥 19 hours ago

🐊 Florida, Iowa, +5 more states – Remote

🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👷‍♀️ Project Manager

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Blue Cross and Blue Shield of Nebraska

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1939

⚕️ Healthcare Insurance

Healthcare Insurance

Blue Cross and Blue Shield of Nebraska is a prominent health insurance provider dedicated to serving the state of Nebraska. With over 80 years of experience, the company offers a range of health insurance plans, including group health, individual and family plans, Medicare, dental, and supplemental insurance options. Known for providing peace of mind, they are committed to ensuring member satisfaction and are recognized for their high-quality coverage and exceptional customer service. Blue Cross and Blue Shield of Nebraska also engages with the community through initiatives like the Nebraska Blue Foundation and emphasizes diversity, equity, and inclusion in its practices. The company is an independent licensee of the Blue Cross Blue Shield Association, providing trusted health coverage and resources to its members.

📋 Description

• Lead the development, interpretation, maintenance, and ongoing evaluation of medical policies using evidence-based clinical literature, national guidelines, regulatory requirements, and coding updates • Analyze emerging technologies, new procedures, pharmaceuticals, and clinical treatments to determine policy implications and organizational impact • Serve as the clinical authority for complex medical policy interpretation and implementation • Recommend policy revisions that improve consistency, quality, compliance, and operational efficiency • Lead evaluation and implementation of ICD-10, CPT, HCPCS, NCCI, CMS, and other industry coding updates impacting claims adjudication • Provide strategic oversight for coding edits and clinical business rules within HealthRules and other claims administration systems • Partner with Configuration and IT teams to translate clinical requirements into system functionality • Identify opportunities to improve automation, reduce manual intervention, and strengthen payment accuracy • Lead enterprise-wide initiatives involving medical policy, payment integrity, claims modernization, and regulatory compliance • Provide expert consultation to executive leadership and business partners regarding complex clinical policy issues • Serve as the clinical liaison across operational, technical, and vendor teams during implementation of strategic initiatives • Evaluate business impacts and recommend solutions that balance clinical appropriateness, member experience, provider relationships, and operational effectiveness • Direct clinical validation, user acceptance testing, and end-to-end testing activities for policy and configuration changes • Ensure policy implementations are accurate, compliant, and operationally effective prior to production deployment • Monitor implementation outcomes and identify opportunities for continuous improvement • Mentor analysts and other team members on medical policy interpretation, coding methodologies, and clinical best practices • Build collaborative partnerships across internal departments and external vendors

🎯 Requirements

• Current Registered Nurse (RN) license in good standing • Bachelor's degree in Nursing (BSN) required; Master's degree in Nursing, Healthcare Administration, Public Health, or related field preferred • Minimum of 5–7 years of progressive clinical nursing experience in an acute care, specialty care, or other complex healthcare setting • Minimum of 3 years of experience in medical policy, utilization management, payment policy, health insurance operations, clinical coding, or related healthcare administration • Advanced knowledge of: ICD-10-CM/PCS CPT HCPCS National Correct Coding Initiative (NCCI) CMS payment methodologies Medical necessity criteria and evidence-based clinical practice • Experience supporting or implementing claims systems, configuration, or healthcare technology solutions • Strong analytical, problem-solving, project management, and communication skills.

🏖️ Benefits

• Health insurance • Paid time off • Flexible work arrangements