Policy Manager

Location 209 10Th Ave S, Suite 350, Nashville, TN, 37203-0752, United States Job Category Corporate Employee Type FT Exempt Policy Manager Overview Policy Manager plays a key role in Wayspring’s work to improve the quality, affordability, and effectiveness of care for individuals with complex behavioral health needs. As a core builder and author of Wayspring’s behavioral health policy library, this person turns evidence into policies that become claims edits, chart-review rubrics, and policy content delivered to health plans. This role is responsible for researching, developing, evaluating, and maintaining behavioral health clinical and payment policies. The Policy Manager will use clinical evidence, healthcare research, regulatory guidance, ASAM criteria, claims and utilization data, coding standards, and industry best practices to develop thoughtful, evidence-based policies that support appropriate care, medical necessity, payment integrity, and responsible utilization of healthcare services. Each policy is written to be precise enough to codify, so it can be applied consistently across utilization management, claims edits, and chart review. This position will work cross-functionally with the Associate Medical Director, clinical leadership, Clinical Auditors, Network Solutions, Analytics, Compliance, Operations, engineering, and health plan partners. The ideal candidate is a strong researcher and critical thinker who enjoys becoming a subject matter expert in complex healthcare topics and can translate research and evidence into clear, practical, and defensible policies. This is a build-stage role: you will help shape how Wayspring writes, approves, and codifies policy, and how quickly the library grows. Why Wayspring? We are passionate about breaking barriers alongside those with complex behavioral health needs. Whether you’re in the field or in the corporate office – our mission is felt, and your impact is recognized. There is no inner circle, and we all have a seat at the table. Leaders are accessible and silos are avoided. We respect your craft and love to be challenged. We invest not only in our mission, but in each other. Internal promotions and cross departmental training are the norm – you grow, we grow. Responsibilities of the Policy Manager Policy Research & Development Research, develop, review, and maintain clinical and payment policies related to behavioral health services Conduct in-depth research of clinical literature, regulatory guidance, reimbursement requirements, coding standards, and industry best practices to support the development of evidence-based policies Research and interpret applicable CMS and Medicare, state Medicaid, ASAM criteria, CPT, HCPCS, ICD-10-CM, and health plan requirements, applicable national practice guidelines, [MF1.1] accounting for differences in Medicaid requirements, behavioral health regulations, and reimbursement practices across states Monitor emerging behavioral health treatment practices, regulatory developments, and industry trends, and work with the Associate Medical Director on policy ideation to identify new policies or updates to existing policies Analyze claims, utilization, provider, clinical, and other healthcare data, along with Network Solutions findings, to identify trends and opportunities that may warrant further research or policy development Evaluate health plan policies, claims rules, utilization management requirements, and reimbursement methodologies to identify opportunities for greater accuracy, consistency, and effectiveness Develop supporting research and recommendations that clearly articulate the evidence and rationale behind proposed policies Policy Library & Content Management Translate complex clinical, regulatory, research, and reimbursement concepts into clear, actionable policies authored in a structured, codifiable format within Wayspring’s content management system Maintain version control, source citations, and organized documentation of research, supporting evidence, policy decisions, stakeholder feedback, revisions, and approvals. Keep the library current by reviewing published policies as clinical evidence, regulations, coding standards, and health plan requirements Meet policy creation throughput goals while managing multiple research and policy initiatives simultaneously Help expand the library into new behavioral health subsectors as Wayspring’s offering grows Policy Approval & Implementation Move policies through the clinical review and approval workflow in partnership with the Associate Medical Director and clinical leadership, ensuring each reflects clinical evidence, medical necessity principles, and the needs of complex behavioral health populations. Partner with coding and engineering teams to translate approved policies into claims-edit logic and rules Help draft and inform chart-review rubrics with clinical leadership so that pre-pay and post-pay reviews apply policy consistently Use findings from Clinical Auditors’ chart reviews to refine policies, rubrics, and claims-edit logic Support behavioral health payment integrity initiatives across the claim lifecycle, including prior authorization and utilization management, claims edits, pre-pay and post-pay chart review, and recovery Support implementation and ongoing evaluation of approved policies, including identifying unintended impacts, provider considerations, operational challenges, and opportunities for refinement Cross-Functional & Health Plan Partnership Partner with Network Solutions, Clinical, Compliance, Operations, and other teams to assess the potential clinical, operational, and financial implications of proposed policy changes Prepare policy documents and supporting materials for review with clinical leadership, internal stakeholders, and health plan partners Test initial policies against health plan expectations, participate in health plan and internal policy discussions, and communicate complex research and policy recommendations in a clear, concise manner Contribute knowledge and research expertise to the continued development of Wayspring’s behavioral health solutions Complete additional projects and responsibilities as assigned Required and Preferred Qualifications Required 3+ years of relevant experience in healthcare research, health policy, behavioral health, clinical policy, payment integrity, utilization management, healthcare analytics, medical coding, claims, reimbursement, or related areas Demonstrated experience working extensively with generative AI and AI-enabled tools, with familiarity building and refining AI-supported research and content workflows. Must be highly comfortable using AI to synthesize complex information, develop and iterate content, and improve efficiency while maintaining strong standards for accuracy, source validation, privacy, and human oversight Demonstrated ability to conduct research on complex healthcare topics and synthesize findings into clear, actionable recommendations Experience evaluating clinical literature, regulatory guidance, healthcare data, industry standards, or similar evidence sources Strong analytical and critical-thinking skills, with an ability to evaluate multiple sources of information and develop well-supported conclusions Excellent written communication skills with the ability to translate complex research and technical information into clear, precise, understandable policy Strong verbal and interpersonal communication skills with the ability to present research findings and policy recommendations to clinical, technical, operational, and client-facing audiences Strong organizational and project management skills with the ability to prioritize multiple initiatives and meet deadlines High level of curiosity and willingness to develop deep subject matter expertise in complex and evolving areas of behavioral health Ability to work both independently and collaboratively in a fast-paced, cross-functional environment Preferred Master’s degree in public health, health policy, healthcare administration, behavioral health, psychology, social sciences, research, or related discipline A strong academic or professional research background, particularly experience conducting literature reviews, evaluating clinical evidence, interpreting healthcare policy or regulatory guidance, and translating complex research into actionable recommendations. Experience with behavioral health, substance use disorder, serious mental illness, Medicaid, managed care, or other complex healthcare populations Knowledge of healthcare reimbursement, medical necessity, utilization management, claims, payment policy, or health plan operations Familiarity with CMS, Medicaid, CPT, HCPCS, ICD-10-CM, and other applicable healthcare standards Familiarity with ASAM criteria and level-of-care determinations for substance use disorder treatment Experience writing medical or payment policy at a health plan or a policy or payment integrity vendor Experience writing structured content for software or rules engines or working closely with engineering teams to translate requirements into logic Experience working within a health plan, managed care organization, value-based care organization, healthcare research organization, provider organization, consulting environment, or similar healthcare setting Experience in a startup or build-stage environment where processes are still being defined[MJ2.1] Our goal is to foster a workplace where everyone feels a true sense of belonging, is supported, and empowered to thrive. We actively seek different backgrounds, perspectives, and experiences - because we believe that drives better performance and innovation. We’re committed to identifying and removing barriers for the communities we serve. Benefit Summary Creating a great employee experience takes more than just perks-but let’s be real, those matter too. Here’s how we’re building a company where you, your family, your pets, and your passions can thrive. Comprehensive Medical, Dental and Vision Insurance options – including options for your pets! Company funded HSA + Monthly Gym Allowance Paid parental leave – all parents included! Company paid short term disability, long term disability and life insurance 401k with company match Premium Employee Assistance Program, inclusive of counseling sessions Pardon and Expungement Scholarship Program Company Contributions to Future Minded Savings (HSA and Emergency savings fund) Generous PTO package (accrual policy based on years of service) and an additional 10 paid company holidays Company 2 week paid sabbatical program! Provider Benefits include ASAM training and membership + $2,500 CEU annual stipend and more! #J-18808-Ljbffr