Clinical Review Specialist

Workforce Classification:

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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