Clinical Policy Coding Administrator

Workforce Classification :

Telecommuter

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 are fostering a culture that emphasizes employee growth, collaborative innovation, and inspired leadership. We are dedicated to creating an environment where employees can excel and where top talent is attracted, retained, and thrives. As a testament to these efforts, Premera has been recognized on the list. Newsweek honored Premera as one of , , and , Forbes ranked Premera among for the fourth time.

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 :

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.

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 :

78, - $122,

National Plus Salary Range :

81, - $139,

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.