Clinical Policy Coordinator

MedPro Group

2d•$90,000 - $110,000•Remote

About The Position

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace. Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market. The Clinical Policy Coordinator is responsible for providing administrative, operational, and research support for the Medical Technology Assessment Committee (MTAC) and other clinical policies and guidelines. This role supports the coordination of committee activities related to utilization management governance, including meeting preparation, evidence gathering, documentation, and follow-up actions associated with clinical review criteria, prior authorization requirements, and related committee decisions. The Clinical Policy Coordinator helps ensure MTAC activities are well organized, appropriately documented, and effectively communicated to support implementation across internal teams and delegated vendors. The role supports enterprise clinical governance by evaluating emerging and updated procedure codes to ensure alignment with benefit strategy, utilization management standards, payment policy, and operational readiness.

Requirements

An active registered nurse (RN) licensure
Minimum of 2+ years of experience in healthcare administration, health insurance operations, utilization management, medical policy, or a related field
Familiarity with prior authorization processes, medical necessity criteria, and/or clinical guideline tools
Experience supporting committees, governance groups, or cross-functional meetings
Exposure to healthcare regulatory, compliance, or audit documentation processes
Familiarity with clinical criteria resources such as MCG, InterQual, LOCUS/CALOCUS, or ASAM
Strong documentation, presentation and project coordination skills
Outstanding organizational, detail oriented and time management skills, including thorough completion of all time sensitive items
Strong written and verbal communication skills
Ability to gather, synthesize, and present information from multiple sources in a clear and organized manner
Ability to adapt in a developing or evolving governance environment
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook
Self-motivated with the ability to work independently and as a member of the team with minimal supervisory direction
Manage multiple priorities, simultaneously in a fast-paced environment
Ability to work effectively with cross-functional teams and stakeholders and manage multiple priorities simultaneously.

Responsibilities

Coordinate MTAC meeting logistics, including calendar management, agenda development support, material preparation, and distribution of meeting documents.
Assist in identifying, organizing, and researching topics for committee review in collaboration with internal stakeholders.
Gather, collate, summarize, and distribute supporting materials for committee consideration, including electronic literature searches, technology assessments, regulatory references, and publications from professional associations, government agencies, and specialty societies.
Support the collection and organization of input from physicians, clinical subject matter experts, and other stakeholders, as needed.
Draft meeting minutes, maintain decision logs, and prepare related committee documentation for stakeholders and leadership.
Assist with drafting and updating clinical review criteria, prior authorization guidelines, code lists, and other supporting materials based on committee direction.
Coordinate follow-up actions resulting from committee decisions and support communication of approved changes to internal departments and delegated vendors.
Maintain organized records of committee materials, supporting evidence, decisions, and implementation documentation.
Support development and maintenance of policies, procedures, workflows, and templates related to MTAC operations.
Assist with implementation activities associated with new or revised guidelines and criteria in coordination with internal teams and external partners.
Review newly released and updated CPT/HCPCS codes to assess applicability to existing benefit structures, utilization management processes, and payment guidelines
Conduct clinical and regulatory research to support evaluation of new procedures/services, including: Peer-reviewed literature, Specialty society guidelines, CMS/AMA publications, Internal claims/utilization trends
Ensure approved coding determinations are operationalized, including: Mapping CPT codes to benefit configurations, Aligning codes with prior authorization rules and clinical edits, Supporting configuration in claims/adjudication systems
Provide clinical support and interpretation to internal teams coding, policy, and benefit questions
Perform other duties as assigned.