Senior Policy Governance Professional

The Senior Policy Governance Professional will monitor enterprise controls for consistent clinical decision-making, develop and adhere to framework processes, and educate stakeholders on clinical decision-making expectations. They will interface with quality audit, clinical policy, process policy, and reporting teams, monitor thresholds, and identify actions for process gaps. Responsibilities include reviewing appeal overturns and provider complaints, driving continuous process improvement, supporting UM strategic initiatives, and identifying potential gaps between intended and actual application of coverage policies. The role involves recommending enhancements to coverage policy templates, supporting decision template development, and acting as a center of excellence for UM delegates and internal partners. They will manage discussions for consistent clinical decision-making, support delegation compliance, and evaluate data on delegate clinical decision-making to mitigate risks. This includes supporting PAL/clinical policy intake processes and managing the plan for MD speaker engagement in CMS program audits, including documentation of roles and expectations, and organizing speaker readiness preparation.