Policy and Coding Research Specialist

Position Summary

The Policy and Coding Research Specialist reports to the Sr. Manager of Utilization Management, Care Management and Quality, working closely with the Senior Medical Director and the Coding and Configuration Manager. The candidate supports and supplies information that translates evidence‑based medical care into policies and procedures that enable a health plan to function. Responsibilities include reviewing clinical, regulatory and industry resources to maintain knowledge of new and emerging technologies and treatments, payor standards for coverage in similar markets, and new CPT, ICD‑10/11 and HCPCS codes for configuration and coverage assignment.

This remote position requires meticulous, self‑directed work and collaboration across the organization. Opportunities for growth are available.

• Review clinical resources and external health plan policies for coverage comparisons.
• Support review of CMS‑designated codes and coding updates; conduct timely review of codes initially designated as exclude at launch or experimental/investigational to determine required code designations, working with the Coding and Configuration Manager.
• Perform research needed for custom code‑configuration lists (e.g., the Chronic Illness Support Program) to support all lines of business and self‑insured employer groups’ benefit coverage requirements, as applicable.
• Monitor regulatory requirements to ensure appropriate code configuration and coverage.

• Serve as part of the Utilization Management Team that collaborates with the Clinical Operations Team to ensure appropriate configuration of codes for billing and auditing.
• Participate in the Clinical Code Review, Benefits and other Committees as requested.
• Work with the Compliance Team to meet regulatory requirements and stay up to date on legislative initiatives.

• Update policies and guidelines within MCG and maintain the license and relationship with the vendor partner.
• Maintain the license and communication with Hayes (symplr) Medical Necessity Guidelines.
• Maintain expert knowledge of ICD‑10 and 11, CPT and HCPCS codes and provide education as necessary.
• Understand current Member Benefit Agreements for all lines of business.

• Support the Utilization Management team with case reviews as needed to maintain compliance.
• Participate in project work or supportive duties as assigned by the Director of Utilization Management, Care Management and UM Appeals, the Coding and Configuration Manager, or Senior Medical Director.

• Proficient in Microsoft Word and Excel and adaptable to use electronic documentation systems, including Salesforce.
• Excellent English communication and writing skills.
• Familiarity with application of MCG Guidelines.

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self‑expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture but our reputation and achievement as well.

Community Health Options DEI initiatives include recruitment and selection, compensation and benefits, professional development and training, promotions, transfers, social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, encouraging.

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

• Valid, unrestricted RN (registered nurse) licensure, Compact or Maine licensed.
• Minimum of 3 years working in a health plan with relevant experience.
• At least 2 years of policy research and development experience.
• Experience in medical necessity reviews within a health plan highly preferred.
• Certified coder, or certification within 6–12 months of hire.

Mid‑Senior level

Full‑time

Strategy/Planning and Information Technology

Insurance