Payer Policy Coordinator

Responsibilities

• Monitor, track, and maintain records of payer medical policies, provider manual updates, coverage determinations, clinical guidelines, and reimbursement policy changes.
• Perform detailed analysis of payer policy and regulatory changes to identify impacts to patient access, reimbursement, clinical operations, and pediatric specialty services, including implications related to Medicaid, CHIP, and other state and federal programs.
• Cook up timely internal reviews by engaging appropriate clinical, pharmacy, operational, and subject-matter experts; organize discussions and consolidate input.
• Draft and coordinate submission of payer responses, comment letters, reconsideration requests, and appeals within required timelines, in collaboration with Legal as needed.
• Develop and maintain a centralized, searchable payer policy repository and notification process for internal stakeholders.
• Prepare and distribute clear, concise policy summaries and impact analyses for leadership and affected departments.
• Provide policy-related analysis and recommendations to support Payer Relations and Contracting teams in contract discussions and compliance monitoring.
• Support preparation of payer performance materials, including scorecards and joint operating committee documentation, related to payer policy impacts.
• Participate in cross-functional initiatives related to utilization management, revenue integrity, and value-based care as they relate to payer policy requirements.

Qualifications

• In-depth knowledge of health insurance medical policies, utilization management processes, and prior authorization requirements.
• Strong understanding of healthcare delivery, including unique clinical, coding, and reimbursement challenges.
• Advanced proficiency in Microsoft Excel (pivot tables, VLOOKUPs, data analysis) and Microsoft Word for policy comparison and documentation.
• Experience with payer provider portals, policy tracking databases, and document management systems.
• Ability to interpret complex medical and reimbursement language and translate it into actionable business and clinical impact statements.
• Familiarity with medical coding (ICD-10, CPT, HCPCS) and revenue cycle terminology preferred.
• Excellent organizational, analytical, and project-management skills with high attention to detail and accuracy.
• Strong written and verbal communication skills, including the ability to prepare professional correspondence and presentations for both clinical and executive audiences.
• Demonstrated success in coordinating cross-functional teams and managing multiple competing priorities with tight deadlines.