Claims Processor IV

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/.

Join us as a Claims Processor IV – Make a Meaningful Impact Every Day!

Step into a role where your expertise ensures individuals and families get the support they deserve. As a Claims Processor IV your attention to detail and commitment to quality will directly impact our members’ lives and uphold our organization’s reputation. Join us and make every claim count—your work truly matters here.

This role is responsible for the accurate and timely review, research, and resolution of moderate to highly complex claims in accordance with contracts and policies. This may include reprocessing claims, organ transplants, SCCA, BDCT, benefit exchanges, and the largest dollar hospital claims. The incumbent will interpret procedures and policies and communicate across business units, i.e.; Configuration, Customer Service, Marketing Liaisons, etc., to ensure accurate claims resolution.

What you will do:

• Enter and process to completion all assigned claims.
• Communicate across business units to resolve claims, i.e.; Configuration, Customer Service, Marketing Liaisons, etc.
• Identify and communicate procedural changes and assist with updating processes and procedures.
• Provide specialized knowledge of complex claims processing to Care Facilitation, Customer Service, Appeals, benefit configuration, and other claims teams, when questions or challenges arise regarding the handling of a complex claim.
• Complete accumulator adjustments, deductible credit loads, and member history reviews to identify claims to be reprocessed.
• Reprocess carve-out claims, researching history and contractual agreements for pricing, override designated claim edits (dup edits, clinical edits, default processing, contracting statues) and complete all reprocessing documentation ( claim notes, CSR routes, refund requests, and configuration question sheets).
• Act as the team subject matter expert including training and auditing claims and providing appropriate feedback and coaching.
• Complete specialized projects as requested by team leader, such as: auditing, procedure updates, and coordination with configuration.
• Consistently meet cycle time/productivity goals that are aligned with corporate objectives.
• Translate data into information acceptable to the claims processing system including follow up on pended claims.
• Maintain confidentiality of all documents/files.
• Apply commitment to quality by doing things right the first time in order to avoid defects from reaching customers or requiring internal re-work.
   

What you will bring:

• High School diploma or GED (Required).
• Two (2) years of claims processing experience in medical and/or dental plans, or 2 years prior medical and/or dental office/insurance industry experience (Required).
• Detailed processing knowledge on Premera processing systems.
• Proven ability to audit other processors.
• Understanding of Out-of-area programs.
• Proficiency and/or experience in another functional area of Premera (M & B, CSR, PIMS, PS&S, or Sales).

What you will gain:

Complex Claims Analysis

• Handling and resolving moderate to highly complex claims, including specialized cases like organ transplants and high-dollar hospital claims.

Cross-Functional Communication

• Collaborating with multiple business units (e.g., Configuration, Customer Service, Marketing Liaisons) to resolve claims and improve processes.

Process Improvement & Auditing

• Identifying procedural changes, updating processes, auditing claims, and providing feedback and coaching to peers.

Technical Proficiency in Claims Systems

• Gaining deeper expertise in claims processing systems and related tools, including accumulator adjustments and reprocessing documentation.

Data Interpretation & Confidentiality

• Translating data into actionable information for claims systems and maintaining strict confidentiality of sensitive documents and files.

Physical Requirements:
The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation:

This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. This role requires the ability to keyboard and to communicate clearly and understandably in person, and over the telephone.

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 careers@premera.com 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.