Medical Policy Coordinator

Blue Cross and Blue Shield of North Carolina•Remote Flex - North Carolina, NC

1d•$81,068 - $129,708•Hybrid

About The Position

The Medical Policy Coordinator develops medical policies that guide coverage for new technologies, medical and dental procedures, and clinical codes (CPT/HCPCS). The role initiates internal and external reviews of corporate medical, dental, and administrative policies to meet regulatory and accrediting requirements, and responds to questions about policies, benefit application, and reimbursement strategies. The coordinator represents the Healthcare Division as a clinical and/or coding advisor and analyzes relevant clinical service codes, including research into new codes, claims-data review, and assessment of system configuration. The position assesses policy and technology using scientific literature, regulatory guidance, clinical practice guidelines, professional statements, and industry resources; develops recommendations and drafts policies; maintains policy websites and manuals; and coordinates communications about policy changes. It also evaluates claims, utilization, reimbursement, and authorization data; collaborates on policy implementation; performs after-hours production system updates and post-configuration testing; leads provider advisory meetings; participates in Blue Cross and Blue Shield Association policy meetings; and works with vendors and stakeholders on laboratory policies and new CMS and AMA codes. The role supports broader initiatives through research, analysis, documentation, and cross-functional coordination. The position uses a Hybrid Flex or Remote Flex arrangement depending on the work and distance from the Durham headquarters. Hybrid Flex employees work in the office at least two days per week; Remote Flex employees work virtually with a few in-office visits each year. Onsite expectations are discussed during the interview process.

Requirements

Registered Nurse or Licensed Practical Nurse.
At least 3 years of experience in a related field.
AAPC Certified Professional Coder certification, or obtain coding licensure within the first year.

Responsibilities

Initiate and coordinate internal and external reviews of medical and dental policies in accordance with regulatory requirements and organizational standards.
Identify opportunities to develop, modify, or update medical and dental policies based on business needs, regulatory changes, emerging technologies, and clinical evidence.
Conduct policy and technology assessments using scientific literature, regulatory guidance, clinical practice guidelines, professional position statements, and industry resources; analyze findings, develop recommendations, and draft policies.
Maintain internal and external medical policy websites and online policy manuals so information is current, accurate, and accessible.
Draft and coordinate provider and member communications about new medical or dental policies and significant coverage-guideline changes.
Serve as a subject matter expert on medical policy, coding, coverage, reimbursement, and integrated benefit design for internal and external stakeholders.
Analyze claims data, utilization patterns, reimbursement trends, and prior authorization activity to evaluate policy performance and recommend policy and process improvements.
Collaborate on medical policy development and implementation projects from initiation through completion, ensuring alignment with federal, state, regulatory, and organizational requirements.
Perform after-hours system updates to promote policy-related application changes from pre-production to production while minimizing operational disruption.
Conduct post-configuration testing of medical policy authorization workflows and business logic, validate functionality and requirements, and provide final business sign-off.
Lead advisory group meetings with specialty providers to review clinical research, scientific literature, and other evidence for potential policy updates.
Participate in Blue Cross and Blue Shield Association medical policy meetings and assess implications of association-level guidance for internal policies.
Collaborate with vendors and internal and external stakeholders to interpret, communicate, and maintain current laboratory policies.
Research newly released CMS and AMA codes to evaluate coverage implications and determine policy and reimbursement requirements.
Support departmental and enterprise initiatives through research, analysis, documentation, and cross-functional coordination.
Provide medical policy expertise to enterprise initiatives focused on reducing operational costs, improving consistency, and increasing transparency in coverage decisions.