Med Policy Coordinator RN

Health and Care
January 27, 2026
Full Time

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Job Description

Job details

Job type

  • Full-time

Full job description

  • Identify and evaluate new treatment and technology for potential coverage by BCBSM/BCN. Develop policies for presentation to various committees, including Joint Uniform Medical Policy (JUMP) and Medical Affairs Policy Review Committee (MAPRC). Develop and maintain a resource base (FDA, BCBSA, CMS, Hayes, etc.) for additional technology and current literature review to support medical policy decisions.
  • Research, analyze and compile supporting documentation of evidence-based literature sourced from national medical professional organizations, peer-reviewed medical literature, specialty associations, society publications and guidelines for medical policy determinations for new policy development and annual review of active medical policies.
  • Coordinate all aspects of policy development and maintenance of assigned medical policies in collaboration with internal team and assigned medical policy directors. The medical policy coordinator is expected to be a medical policy subject matter expert that can advise and partner with the team throughout the medical policy process.
  • Provide clinical knowledge and medical policy expertise for medical policy development and maintenance, inquiries, projects, initiatives, and work groups as related to medical policy interpretation and coding (ICD-10, CPT, HCPCS) of services identified on policies.
  • Respond to moderate and complex medical policy inquiries to ensure appropriate medical policy interpretation and utilization of policy criteria.
  • Active participation in consultations with internal teams and external practitioners, providers, medical groups and professional associations, as necessary, to obtain advice and expertise in development and maintenance of medical policies.
  • Other duties as assigned by leadership.

Department Preferences:

  • Excellent research skills which include the ability to analyze peer-reviewed medical literature for statistical significance.
  • Excellent written communication skills including grammar, spelling, punctuation and standardized formatting to produce professional medical policies published for both internal and external stakeholders.

” Qualifications “

  • 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 Registered Nurse license required.
  • Self-motivated, ability to work independently and as part of a team, ability to motivate team.
  • Excellent verbal and written communication skills required.
  • Excellent organizational skills, multi-tasking and timelines with planning and development required.
  • Excellent interpersonal skills. Ability to interact internally and externally at all levels of the organization required.
  • 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 and 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.
  • PC literate in commonly utilized software programs.

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