Clinical Review Specialist

The Clinical Review Specialist at Premera conducts detailed clinical and coding evaluations to ensure claim payments are accurate and compliant with policies and industry standards. The role requires clinical judgment, coding proficiency, and collaboration with internal and external stakeholders to improve review processes and claim outcomes.

Location: Remote

Salary: $80,200.00 - $125,600.00 /yr

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.

Requirements

• Bachelor's Degree or (4) years of work experience.
• (4) years of analytical experience in a technical, healthcare, or business-related discipline, including (2) years of experience leading small to medium size projects.
• Comprehensive knowledge of CPT, ICD10, HCPCS or other coding structures.
• 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)
• Experience with claim editing tools, configurations, updates, and troubleshooting. (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 a pension plan vested after 3 years of service.
• Wellness incentives with mental well-being resources, counseling services, stress management, and mindfulness programs.
• Generous paid time off.
• Tuition assistance for undergraduate and graduate degrees.
• Employee recognition program.
• On-campus resources and networking opportunities for hybrid employees.
• Commuter perks and free on-site parking.
• Subsidized on-campus cafes.
• Engaging on-site activities and wellness events.
• Fitness & well-being center with in-person and virtual workouts.

Additional Information

• Premera is an equal opportunity employer.
• Open to applicants in multiple states with some role or city limitations.
• Salary varies based on location, market conditions, skills, and experience.
• The posted salary range is $80,200 - $125,600, with a higher 'Plus' range for certain markets.