Join to apply for the Medical Policy Program Manager role at Commonwealth Care Alliance .

Check out the role overview below If you are confident you have got the right skills and experience, apply today. Position Summary The Medical Policy Program Manager is responsible for researching, analyzing, developing, and disseminating medical policies related to medical and behavioral health services (e.g., procedures, DME, Part B drugs) and services addressing social determinants of health across all products and geographies. They collaborate with key organizational stakeholders to ensure policies comply with regulatory, accreditation, and contractual requirements. The role requires expertise in medical policy development and review, working with the Sr. Medical Director and other subject matter experts to translate industry standards into organizational policies, develop recommendations, and monitor emerging healthcare technologies and products. Responsibilities Stay updated on state and federal mandates, regulations, and policies impacting medical policies. Coordinate annual reviews of existing medical policies with the Knowledge Hub Team. Support development and review of policies across departments, ensuring alignment with regulatory and contractual standards. Participate in evaluating the effectiveness of medical policies and prior authorization programs. Assist payment and claims teams in developing relevant payment policies. Lead the development and review of medical necessity guidelines, conducting research and aligning with clinical needs. Manage special projects as assigned. Ensure compliance with applicable laws, regulations, and policies. Collaborate on provider manuals and training materials to ensure consistency with policies. Represent the Medical Policy team in meetings and organizational projects. Working Conditions Standard fully remote office environment. Qualifications Required Education: Bachelor's degree in nursing or health-related field. Desired Education: Master’s in public health, Healthcare Administration, or similar. Licenses: Active clinical license (e.g., nursing, physical therapy, LICSW), Certified Professional Coder (CPC), Medical Billing and Coding Certification. Experience: Minimum 2 years’ clinical experience and 2 years’ experience in healthcare delivery or public health/public policy, with experience managing cross-functional projects. Skills & Abilities: Policy research and development, excellent communication, ability to work collaboratively, proficiency in Microsoft Office, leadership, organizational skills, and attention to detail. Additional Information Position is mid-senior level, full-time, in the healthcare industry, based in Boston, MA with salary range $80,000-$120,000.

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