Clinical Policy Coding Administrator

November 21

🐻 Alaska – Remote

Although this job is listed in Alaska, this company may be open to hiring remote in other states.

🌵 Arizona – Remote

Although this job is listed in Arizona, this company may be open to hiring remote in other states.

+25 more states

🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ☕ Washington – Remote 🧀 Wisconsin – Remote

💵 $78k - $122.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🖥️ Administration

🦅 H1B Visa Sponsor

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Premera Blue Cross

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Healthcare Insurance

Premera Blue Cross is an independent health insurance provider, serving businesses and residents of Washington State and Alaska as a licensee of the Blue Cross Blue Shield Association. The company offers a range of health plans including individual, family, employer-based, and Medicare Supplement plans. However, it has announced that it will exit the Medicare Advantage market as of January 1, 2025. Premera is committed to advancing health equity and community support, evident through its Social Impact Program focused on behavioral health and homelessness solutions in Washington and Alaska. Additionally, Premera complies with federal and state civil rights laws, offering language assistance services to ensure equitable care.

1001 - 5000 employees

Founded 1945

⚕️ Healthcare Insurance

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

• 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.