Premera Blue Cross · 12 hours ago
Clinical Policy Coding Administrator
United States
Full-time
Remote
Mid, Senior Level
$80K/yr - $126K/yr
4+ years expPremera Blue Cross is committed to improving healthcare for its customers. The Clinical Policy Coding Administrator plays a critical role in managing healthcare costs by coordinating medical policy operations and clinical coding to ensure accurate claims processing and payment for services.
Cyber SecurityHealth CareInformation TechnologyInsurance
Responsibilities
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
Qualification
Required
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
Previous payer or health plan experience
Preferred
Claims processing systems and product configuration experience including familiarity with supplemental tables and product configuration
Experience/knowledge of claims processing with a working knowledge of different claim types is desired
Current Washington State License: Registered Nurse (RN), Advanced Registered Nurse Practitioner (ARNP), or Physician's Assistant (PA)
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.
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.
Company
Premera Blue Cross
Premera is a leading health plan in the Pacific Northwest, providing comprehensive health benefits and tailored services.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Jeffrey Roe
President and Chief Executive Officer
Talha Ashraf
EVP and CFO
Recent News
2025-12-04
TechTarget
2025-10-31
Company data provided by crunchbase