Clinical Policy Coding Administrator

Workforce Classification:

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.

Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/.

About the role of Clinical Policy Coding Administrator

The Clinical Policy Coding Administrator is a senior member of the Medical Policy and Clinical Coding team whose work is critical in managing healthcare costs. In this compelling and challenging role, you will work with a dynamic team of experts that pull together medical policy operations and clinical expertise to make decisions that ensure members receive safe services and accurate payment for those services. The Clinical Policy Coding Administrator will focus on identifying and coordinating appropriate codes to support claim system edits that direct payment of medical services. This individual will be a liaison between the clinical and operations teams, working to bring the two aspects of the business together to inform configuration that supports accurate claims processing. Act as a key resource and contact for clinical coding, the Clinical Policy Coding Administrator will draw on their knowledge of medical policy and clinical coding to identify the appropriate codes that accurately represent services. Collaboration with configuration teams (i.e.., Claims and Product) is vital to ensure codes are established in the system in order to pay claims appropriately.

What you’ll 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 (Utilization Management) 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 between Clinical Review, Healthcare Services, and other departments 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 trending to confirm alignment of code payments, changes and denials, and medical policy changes.
• Contribute to the analysis and decision-making efforts of the provider appeal process including assessment of appropriate coding, medical record review, and Correct Coding Initiative (CCI) bundling edits, and recommend action steps regarding code configuration issues, annual utilization and review analysis.
• Maintain current knowledge of coding application for current ICD 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’ll bring:

• Bachelor's degree or four (4) years’ relevant work experience. (Required)
• Current Certified Professional Coder (CPC) certification. (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)
• Previous payer or health plan experience. (Required)
• Claims processing systems and product configuration experience including familiarity with supplemental tables and product configuration. (Preferred)
• Experience/knowledge of claims processing with a working knowledge of different claim types is desired. (Preferred)
• Current Washington State License: Registered Nurse (RN), Advanced Registered Nurse Practitioner (ARNP), or Physician’s Assistant (PA). (Preferred)
• Ability to influence organizational effectiveness by providing input and general engagement in support of initiatives and project work related to change.
• Knowledge of health insurance industry trends, new technology, utilization management, and familiarity with state and federal mandates.
• Self-starter with strong analytical skills and the demonstrated ability to think critically, solve business problems and understand/summarize complex, technical information and make independent, informed recommendations.
• Working knowledge of billing, coding, claims processing, medical terminology and anatomy.
• Working knowledge of Microsoft Office.
• Demonstrated ability to establish positive working relationships throughout the corporation and influence others to resolve issues and make decisions.

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• Medical, vision, and dental coverage with low employee premiums.

• Voluntary benefit offerings, including pet insurance for paw parents.

• Life and disability insurance.

• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.

• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.

• Generous paid time off to reenergize.

• Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.

• Employee recognition program to celebrate anniversaries, team accomplishments, and more.

For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.

• Commuter perks make your trip to work less impactful on the environment and your wallet.

• Free convenient on-site parking.

• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.

• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.

• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.

• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

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.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

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.

The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

National Salary Range:

National Plus Salary Range:

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

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.