Clinical Review Specialist

Workforce Classification:

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. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog:  https://healthsource.premera.com/.

About the role of Clinical Review Specialist

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.

What you’ll do:

• 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.

What you’ll bring:

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

Knowledge, Skills, and Abilities

• 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.

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• 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.

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, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [email protected] or via phone at 425-918-4785.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

National Salary Range:

National Plus Salary Range:

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.