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Clinical Policy Coding Administrator

Clinical Policy Coding Administrator
Locations: Telecommuter
Time Type: Full time

Job Requisition Id: R26325

Join Our Team: Do Meaningful Work and Improve People’s Lives

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership.

Forbes ranked Premera among America’s 2023 Best Midsize Employers because we are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

This is a Work from Home Opportunity!!

As a Clinical Policy Coding Administrator for the Medical Policy and Clinical Coding team, you will work with a dynamic team of experts that pull together medical policy operations and clinical expertise to inform decisions that ensure members receive safe services and accurate payment for those services. The Clinical Policy Coding Administrator will focus on identifying and applying appropriate codes to support claim system edits that direct payment of medical services. You will be a liaison between the clinical and operations teams, working to bring the two aspects of the business together and making sure prior authorization applies to the appropriate services on the front end and that members claims are paid as expected once the service is performed.

Using your knowledge and expertise as a certified clinical coder, you will be the key contact for analyzing medical policies and identifying the appropriates codes to represent services, then collaborating with system configuration to ensure payment systems accurately process the member’s claims. Other work involves collaborating with benefits, preventive services, partnering with vendors on their coding requirements, reviewing provider appeals, assessing pricing determinations at claims level, managing the auto authorization process, supporting implementation of mandates, and many other special projects.

What you will do:

  • Collect and analyze data to evaluate the effectiveness of medical policy implementation, identify and update appropriate procedure and diagnosis codes, and support business decisions regarding utilization management activities and guidelines.
  • Support medical policy development and implementation by identifying and updating appropriate procedure and diagnosis codes for company medical policies and UM guidelines that reflect medical necessity, experimental/investigational or other code categories.
  • Provide subject matter expertise for the Medical Policy Implementation Workgroup to ensure cross-functional collaboration within Healthcare Services, and other areas on coding edit decision-making related to medical policies and mitigate downstream impact.
  • Perform analysis, research, and assessment in response to cross-functional requests to inform accuracy and consistency for claims processing, reimbursement, benefit, and product configuration issues.
  • Develop and use data gathering tools to document and analyze patterns of code payments and denials, medical policy changes, and coding changes.
  • Research and interpret medical claims utilization and program participation. Present findings to internal customers to assist them in managing healthcare costs and improved member satisfaction.
  • Identify potential patterns and/or trends to confirm alignment of code payments, changes and denials, and medical policy changes.
  • Provider appeal review determinations including assessment of appropriate coding, medical record review, and Correct Coding Initiative (CCI) bundling edits.
  • Recommend pricing guidance for by report procedures at the claims level.
  • Recommend action steps regarding code configuration issues, annual utilization, and review analysis to aid clinical review teams.
  • Maintain current knowledge of coding application for current medical coding and other applicable coding systems that apply to medical documentation and claims.
  • Provides subject matter expertise to a variety of internal committees as assigned.
  • Completes special projects and other duties as assigned.

What you will bring:

  • Bachelor’s degree or four (4) years’ relevant work experience. (Required)
  • Current certification as a professional coder (RHIA, RHIT or CPC). (Required)
  • Four (4) years of experience applying clinical coding expertise with two (2) of those years spent in a health plan or healthcare setting. (Required)
  • Claims processing systems and product configuration experience including familiarity with supplemental tables and product configuration.
  • Experience/knowledge of claims processing with a working knowledge of different claim types is desired.
  • Current Washington State License: Registered Nurse (RN), Advanced Registered Nurse Practitioner (ARNP), or Physician’s Assistant (PA) (Bonus not required)

What we offer

  • Medical, vision and dental coverage
  • Life and disability insurance
  • Retirement programs (401K employer match and pension plan)
  • Wellness incentives, onsite services, a discount program and more
  • Tuition assistance for undergraduate and graduate degrees
  • Generous Paid Time Off to reenergize
  • Free parking

Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.
National Salary Range: $68,400.00 – $116,300.00
National Plus Salary Range: $77,300.00 – $131,400.00

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.

About Us
At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives.

As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services.

Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.