Policy Manager

Show Map

Location 209 10Th Ave S, Suite 350, Nashville, TN, 37203-0752, United States

Job Category Corporate

Employee Type FT Exempt

Description

Policy Manager Overview

The 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 an