Premera Blue Cross
Improve customers' lives by making healthcare work better.
Clinical Review Specialist
Location
Alaska + 26 moreAll locations: Alaska, Arizona, California, Colorado, Florida, Idaho, Iowa, Kansas, Kentucky, Maine, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Michigan, Minnesota, Missouri, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin
Posted
35 days ago
Salary
$80.2K - $125.6K / year
Bachelor Degree4 yrs expEnglishMS SQL ServerSQL
Job Description
• Conduct detailed clinical and coding evaluations to ensure claim payments are accurate.
• Review medical records and appeal submissions to assess coding accuracy.
• Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing and auditing.
• Coordinate with vendors and internal teams to design and implement payment integrity solutions.
• Collect, analyze, synthesize, and interpret multiple sources of data.
• Lead technology/tool updates, testing, and troubleshooting with IT teams and vendors.
• Respond to payment integrity inquiries from providers, internal teams, and vendors.
• Manage multiple projects or audits with minimal supervision.
• Collaborate with appropriate departments regarding payment integrity issues identified during auditing processes.
• Develop and facilitate presentations by analyzing and interpreting data to communicate business issues and findings.
Job Requirements
- Bachelor's Degree or (4) years of work experience. (Required)
- (4) years of analytical experience in a technical, healthcare, or business-related discipline, including (2) years of experience leading small to medium size projects. (Required)
- Comprehensive knowledge of CPT, ICD10, HCPCS or other coding structures. (Required)
- Current State Licensure as a Registered (RN) or Licensed Practical (LPN) Nurse where licensing is required by state law. (Strongly preferred)
- (4) years of experience with healthcare claims processing systems or provider billing and revenue cycle management systems. (Preferred)
- Certified Professional Coder designation. (Preferred)
- Certified Internal Auditor. (Preferred)
- Previous Payor experience. (Preferred)
- Certified as a Six Sigma or Lean leader. (Preferred)
- Experience with various querying tools, including MS SQL Server, SAS. (Preferred)
- Demonstrated advanced skills in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint. (Preferred)
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 pension plan.
- Wellness incentives with mental well-being resources and counseling services.
- Generous paid time off.
- Tuition assistance for undergraduate and graduate degrees.
- Employee recognition program for anniversaries and team accomplishments.
- On-campus model for hybrid employees, including access to resources and team engagement.
- Commuter perks and on-site parking.
