Med Policy Coordinator RN

Med Policy Coordinator RN Job Description

• Identify and evaluate new treatment and technology for potential coverage by BCBSM/BCN, developing policies for presentation to committees such as Joint Uniform Medical Policy (JUMP) and Medical Affairs Policy Review Committee (MAPRC).
• Research, analyze, and compile evidence‑based literature from national medical professional organizations, peer‑reviewed journals, specialty associations, and guidelines to support medical policy determinations for new policy development and annual review of active policies.
• Coordinate all aspects of policy development and maintenance of assigned medical policies in collaboration with internal teams and medical policy directors, serving as a subject matter expert.
• Provide clinical knowledge and medical policy expertise for development, maintenance, inquiries, projects, initiatives, and work groups, including coding (ICD‑10, CPT, HCPCS) for services identified on policies.
• Respond to moderate and complex medical policy inquiries to ensure appropriate interpretation and utilization of policy criteria.
• Participate in consultations with internal and external stakeholders, including practitioners, providers, medical groups, and professional associations, to obtain advice and expertise for policy development and maintenance.
• Perform other duties as assigned by leadership.

• Excellent research skills, including analysis of peer‑reviewed medical literature for statistical significance.
• Excellent written and oral communication skills, grammar, spelling, punctuation, and standardized formatting to produce professional medical policies.
• Ability to present assigned policies, including supporting rationale, to large committees.

• Bachelor’s degree required; major in nursing or other health‑care related field preferred.
• Four (4) years broad clinical experience required.
• Three (3) years utilization/quality management experience required; managed‑care environment preferred.
• Two (2) years medical policy or benefit determinations experience preferred.
• Two (2) years coding or medical billing experience preferred.
• Registered Nurse with current unrestricted Michigan RN license required.
• Self‑motivated, able to work independently and as part of a team, with strong motivation skills.
• Excellent verbal and written communication skills required.
• Excellent organizational skills, multi‑tasking, and planning and development of timelines required.
• Excellent interpersonal skills; ability to interact internally and externally at all levels of the organization.
• Demonstrated problem‑solving and decision‑making skills.
• Demonstrated research and analytical skills.
• Demonstrated understanding of primary code classifications, ICD‑10, CPT, and HCPCS (preferred).
• Knowledge of Facets and system configuration required.
• Knowledge of policies and procedures, member certificates (riders, waivers, exclusions and limitations) preferred.
• Knowledge of CMS benefit guidelines preferred.
• Knowledge of BCBSM medical management policies, procedures, processes, claims processing flow, and utilization management policies and procedures preferred.
• Knowledge of BCBSM/BCN reimbursement policies preferred.
• Knowledge of NCQA, CMS, State, and Federal HMO regulations preferred.
• Knowledge of current medical and clinical practices, including community standards of practice.
• PC literate in commonly utilized software programs.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.