Clinical Advisor, Medical Policy  


Location: Raleigh, NC


Position Purpose: Reporting to the Director of Medical Policy, the Clinical Advisor will serve as the primary reviewer of Clinical Policies before these are presented to the Medical Affairs Committee and/or Clinical Policy Workgroups. In collaboration with Director of Medical Policy, the Clinical Advisor will be an invaluable resource in assisting to provide clinical feedback on updated/new Clinical Policies. This individual will also assist in identifying data needs specific to Clinical Policies.  


In this role, you will:

·        Coordinates the process to develop/revise medical policies.

·        Works with Carolina Complete Health Network’s CEO, Carolina Complete Health’s Chief Medical Officer, and Director of Medical Policy to coordinate the activities of the advisory committees established by Carolina Complete Health’s Medical Affairs Committee, to identify policy gaps, data needs for workgroups, and written revisions to policy.

·        Assists Carolina Complete Health Network’s CEO and Carolina Complete Health’s Chief Medical Officer in planning and establishing goals and policies to improve cost-effectiveness of care and service for members.

·        Facilitates the adoption of clinical practice guidelines.

·        Collaborates with health plan, internal, and external stakeholders to develop policy agendas.

·        Provides clinical leadership for utilization management, cost containment, and medical quality improvement activities specific to clinical policy.

·        Assists in performing medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.

·        Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, health plan, and accreditation requirements.

·        Oversees the development and implementation of physician education with respect to clinical issues and policies in collaboration with the Director of Medical Policy.

·        Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

·        Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

·        Interfaces with physicians and other providers in the provider network to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

·        Works in collaboration with the Medical Policy Coordinator to ensure peer review of medical policies.

·        Works in collaboration with Director of Medical Policy to extrapolate from medical policies implications on various other departments


Minimum Qualifications:

·        Registered Nurse

·        Experience in direct clinical care as a licensed professional.

·        Course work in the areas of Health Administration, Health Financing, Insurance, preferred.

·        Experience treating or managing the care for a culturally diverse population preferred.

·        Previous experience with managed care organization preferred.

·        10+ years of experience relevant to the Position Description.

Additional Job Information/Requirement:

·        This is a part-time/hourly position requiring work availability between standard daytime working hours



Carolina Complete Health Network is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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