Clinical Guidelines Analyst - With CPC and Insurance/Healthcare experience

1. JOB PURPOSE

The Clinical Guidelines Executive is responsible for developing, implementing, and maintaining clinical guidelines based on international treatment standards, customized to align with Nas Neuron's payer and internal policies. The role supports the Utilization Review & Management team by creating guidelines that ensure all medical services provided to members are clinically appropriate, cost-effective, and consistent with high-quality care standards.

2. RESPONSIBILITIES AND DUTIES

Key Responsibilities:

1. Guideline Development: Research and compile clinical guidelines using international treatment standards and evidence-based practices, customizing them to meet the specific requirements of Nas Neuron's payer and internal policies.

2. Policy Alignment: Ensure clinical guidelines align with insurance coverage criteria, establishing clear criteria for medical necessity and service appropriateness.

3. Documentation and Repository Maintenance: Develop and maintain a centralized repository of clinical guidelines and ensure they are readily accessible to stakeholders within the organization.

4. Cross-functional Collaboration: Collaborate with Medical Operations, Coding, and Claims Review teams to ensure guidelines are effectively implemented and understood across departments.

5. Continuous Update and Training: Stay current with updates in international treatment standards, continuously update guidelines, and provide necessary training to team members on guideline changes.

3. KNOWLEDGE, SKILLS AND EXPERIENCE

Education: Bachelor’s degree in medicine, Nursing, Health Administration, or a related clinical field.

Skills and Competencies:

Technical and Analytical Skills

• Clinical Knowledge: Strong understanding of international treatment guidelines and evidence-based standards (e.g., NICE, AHRQ, WHO) to create guidelines that are relevant to the healthcare insurance context.
• Medical Coding Proficiency: Familiarity with medical coding (ICD-10, CPT) the tools available for coding and the ability to apply coding guidelines in line with clinical protocols and insurance requirements.
• Analytical Skills: Strong analytical skills to research, interpret, and adapt international clinical guidelines into practical, customized guidelines for insurance coverage policies.

Communication and Documentation

• Clear Documentation Skills: Ability to compile, organize, and document clinical guidelines into a well-maintained and easily accessible repository.
• Effective Communication: Excellent verbal and written communication skills, with the ability to clearly convey complex clinical guidelines to internal teams, including non-clinical stakeholders.

Collaboration and Interpersonal Skills

• Cross-functional Collaboration: Strong interpersonal skills to work effectively with Medical Operations, Coding, and Claims Review teams, ensuring smooth implementation and understanding of guidelines.
• Stakeholder Engagement: Ability to support team members and communicate updates on clinical guidelines, addressing inquiries or challenges in the application of guidelines.

Continuous Learning and Adaptability

• Adaptability to Regulatory and Industry Changes: Ability to stay current with updates to international guidelines, healthcare regulations, and insurance industry standards, making timely revisions to ensure guidelines remain relevant.
• Detail-oriented Approach: Keen attention to detail to ensure all guidelines are accurate, thorough, and compliant with insurance coverage criteria.

Problem-solving and Improvement Mindset

• Problem-solving Abilities: Capability to identify gaps or issues in existing guidelines and proactively recommend adjustments or improvements to maintain efficiency and accuracy.
• Commitment to Continuous Improvement: Motivation to stay updated with emerging evidence-based practices and integrate improvements that support the organization’s standards of care and operational goals.

· Ethical and professional: High standards of integrity and compliance, with a commitment to delivering the best possible care to members.

Key Attributes

1. Detail-Oriented

• Meticulousness: Ability to thoroughly review clinical guidelines, ensuring accuracy and alignment with evidence-based practices and regulatory standards.
• Precision: Focus on detail when drafting and maintaining guidelines to avoid ambiguity and ensure clarity for healthcare providers.

2. Analytical Thinker

• Critical Analysis: Skill in evaluating clinical evidence, treatment protocols, and guidelines to ensure they are relevant and effective.
• Problem-Solving Orientation: Capability to identify gaps in existing guidelines and recommend improvements based on data and feedback.

3. Collaborative

• Interpersonal Skills: Strong ability to work with multidisciplinary teams, including medical committees, healthcare professionals, and internal stakeholders.
• Team Player: Willingness to engage with others to refine guidelines and ensure they meet the needs of both patients and providers.

4. Ethical and Professional

• Integrity: Commitment to maintaining high ethical standards in the development and dissemination of clinical guidelines.
• Professionalism: Approaches all tasks with a high degree of professionalism, respecting confidentiality and compliance with regulations.

5. Strategic Mindset

• Long-Term Vision: Ability to see beyond immediate tasks and understand the broader implications of guidelines on healthcare delivery and outcomes.
• Proactive Approach: Takes initiative to address emerging clinical issues or changes in medical practice that may require updates to guidelines.

6. Effective Communicator

• Clear Communication: Ability to convey complex clinical information and guidelines in a manner that is easily understood by healthcare providers and non-clinical stakeholders.
• Educational Skills: Proficient in educating healthcare teams about new guidelines and protocols, facilitating understanding and compliance.

7. Research-Oriented

• Commitment to Evidence-Based Practice: Passion for staying updated on the latest clinical research, treatment modalities, and best practices.
• Curiosity: A desire to explore new developments in healthcare that could inform guideline updates and improvements.

8. Adaptable

• Flexibility: Ability to adjust guidelines based on evolving clinical evidence, regulatory requirements, and organizational needs.
• Resilience: Maintains focus and effectiveness in a fast-paced healthcare environment, especially when faced with complex clinical challenges.

Work Experience: 2-3 years of experience in clinical guideline development, utilization review, or clinical operations within healthcare or insurance.

Job Type: Full-time

Pay: AED8,000.00 - AED10,000.00 per month

Education:

• Bachelor's (Preferred)

Experience:

• Insurance: 3 years (Preferred)
• Coding: 2 years (Preferred)