Premera Blue Cross Clinical Policy Administrator in Mountlake Terrace, Washington

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. So are our employees. Working at Premerameans you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

As a Clinical Policy Administratorfor our Medical Policy and Clinical Coding team, you will work with a dynamic team of experts that pull together medical policy operations and utilize clinical expertise to make decisions that ensure our members receive safe services and accurate payment for those services. You will focus on identifying and coordinating 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 make sure our members claims are paid as expected. We’d like you to provide your knowledge and experience to help make great decisions, contribute to refine department processes, and elevate engagement between internal teams. As a key contact for clinical coding, you’ll draw on your knowledge of medical policy and clinical coding to identify the appropriate codes to represent services, then collaborate with our system configurations team to ensure codes are established in the system to pay claims appropriately.

What you’ll 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

  • Influence organizational effectiveness, provide input and general engagement in support of initiatives and project work related to change

  • Identify potential patterns and/or trending to confirm alignment of code payments, changes and denials, and medical policy changes

  • Research, interpret, and present medical claims utilization and program participation to internal customers to assist them in managing healthcare costs and improve member satisfaction

  • 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

What you’ll bring:

  • Bachelor's degree or four (4) years’ relevant work experience

  • Current Certified Professional Coder (CPC) certification

  • Four (4) years of experience applying clinical coding expertise with two (2) of those years spent in a health plan or healthcare setting

  • Experience/knowledge of claims processing with a working knowledge of different claim types is desired

  • Claims processing systems configuration experience including familiarity with supplemental tables and product configuration is highly valued

  • 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

What we offer: Premera is proud to offer a comprehensive benefits package including:

  • Medical, vision and dental coverage

  • Life and disability insurance

  • Retirement programs (401K employer match and pension plan)

  • Wellness incentives, onsite services, a discount program and more

  • Tuition assistance for undergraduate and graduate degrees

  • Generous Paid Time Off to reenergize

  • Free parking


Job Title: Clinical Policy Administrator

Job ID: 11488

Location: Mountlake Terrace, WA

Full/Part Time: Full-Time

Regular/Temporary: Regular

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, national origin, gender or gender identity, sexual orientation, age, genetic information, disability or veteran status. All staff of Premera and its subsidiary companies must demonstrate the legal right to work in the United States. Premera is an E-Verify employer.