Clinical Review Specialist

Premera Blue Cross

5d•Remote

About The Position

As a Clinical Review Specialist for Premera, you will be responsible for conducting detailed clinical and coding evaluations to ensure claim payments are accurate and aligned with Premera policies and industry coding and billing standards. Using advanced coding expertise and your previous clinical experience, you will review medical records and appeal submissions to assess coding accuracy. The Clinical Review Specialist requires strong clinical judgment, coding proficiency, critical thinking, and the ability to identify discrepancies between billed services and the documented care. You will collaborate with internal teams and external stakeholders to promote consistency and accuracy in claim outcomes, while contributing to ongoing improvements in review processes and quality standards.

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)
Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies.
Demonstrated project management experience.
Exceptional analytical skills - demonstrated ability to ensure reliability and relevance of data collected.
Excellent written communication skills - demonstrated ability to compose sensitive, non-routine correspondence requiring tact and diplomacy.
Excellent speaking and presentation skills - demonstrated ability to deliver presentations regarding controversial issues, ability to deliver talks and/or speeches before groups and audiences.
Exceptional problem-solving skills - demonstrated ability to solve a wide range of highly complex, multi-disciplinary problems, which must consider long-term company-wide planning.

Nice To Haves

(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)
Experience with claim editing tools, configurations, updates, and troubleshooting. (Preferred)
Demonstrated advanced skills in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint. (Preferred)

Responsibilities

Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing, pre-payment claims auditing, contract compliance, post-payment payment integrity solutions, etc.
Coordinate with vendors and internal teams to design, propose, implement, prioritize, and oversee payment integrity solutions that increase claim payment accuracy.
Collect, analyze, synthesize, and interpret multiple sources of quantitative and qualitative data. Extract key insights to draw conclusions and prepare recommendations to make strategic and operational decisions.
Proficiency with payment integrity tools, such as but not limited to, Optum CES, ClaimXTen, and Pareo.
Lead technology/tool updates, testing, and troubleshooting with internal IT teams and external vendors.
Effectively respond to payment integrity inquiries from providers, internal teams, appeals, and vendors.
Manage scope of multiple projects or audits with minimal direction and supervision.
Collaborate with appropriate departments regarding payment integrity issues identified during editing or auditing processes.
Develop and facilitate presentations by analyzing and interpreting data to communicate business issues, findings, and recommendations.

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.