Medical Policy & Special Project Clinical Analyst - RN

## Medical Policy & Special Project Clinical Analyst - RNApplylocations:
Work at Home - Nebraska time type:
Full time posted on:
Posted 5 Days Agojob requisition :
JR101348

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

The Medical Policy & Special Projects Clinical Analyst serves as the organization's senior clinical subject matter expert for medical policy development, clinical coding strategy, and complex claims configuration initiatives. This role provides strategic leadership in translating evolving clinical practice, regulatory guidance, coding updates, and evidence-based medicine into operational medical policies and claims processing solutions.
The analyst partners across Medical Management, Provider Network, Claims Operations, Information Services, Configuration, Compliance, and Clinical Leadership to evaluate emerging healthcare trends, assess business impacts, and implement enterprise-wide policy and system enhancements. This position leads complex cross-functional initiatives, provides expert consultation on highly specialized clinical issues, and ensures medical policies align with organizational strategy, regulatory requirements, and industry best practices.
** Candidates applying to this remote nursing position can live in one of the following states:
Florida, Iowa, Kansas, Missouri, Nebraska, North Dakota, and Texas.
**** What You'll Do
**** Medical Policy Leadership (10%)
*** 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.
** Clinical Coding & Claims Strategy (25%)
*** 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 Health Rules 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.
** Enterprise Projects & Clinical Consultation (20%)
*** 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.
** Quality Assurance & Operational Excellence (35%)
*** 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.
** Leadership & Collaboration (10%)
*** Mentor analysts and other team members on medical policy interpretation, coding methodologies, and clinical best practices.
* Build…