Registered Nurse Quality Review Specialist - CIC or CCS

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This role involves an indepth review of provider submitted appeals of medical claims, that have been previously been subject to a Payment Integrity finding, to ensure the accuracy and compliance of claim findings. The clinician will prepare and review provider appeal requests, validate accuracy of ICD-10-CM/PCS coding, and ensure proper reimbursement. This role requires strong clinical knowledge, medical coding expertise, and excellent analytical and communication skills.

ESSENTIAL RESPONSIBILITIES

• Review and analyze medical claims for accuracy and compliance with inpatient standards, accuracy of ICD-10-CM/PCS coding, ensuring compliance with current coding guidelines and regulations
• Prepare comprehensive appeals, including detailed narratives and supporting documentation, to address determinations, and submit determinations to providers in a timely manner.
• Maintain detailed and organized records of claims, reviews, and appeals.
• Stay updated with current healthcare regulations and policies
• Provide expertise and guidance on inpatient claim processed and best practices.
• Follow up with providers to ensure timely resolution of appeal requests, including providing feedback to providers and coding staff on coding accuracy and documentation requirements.
• Identify trends in denials and coding issues and collaborate with providers to improve documentation and coding practices.
• Other duties as assigned or requested.

EXPERIENCE

Required

• 3 years of experience in Clinical setting
• 3 years of experience in Medical claim review
• 3 years of experience with Proficiency in medical coding and healthcare software systems
• 3 years of experience in Familiarity with payer policies and regulations

Preferred

• 3 years of experience with electronic health systems

SKILLS

• Strong analytical, communication, and problem-solving skills
• Strong understanding of ICD-10-CM/PCS coding guidelines and medical terminology
• Ability to work independently and as part of a team

EDUCATION

Required

• Associate's degree in Science of Nursing or relevant experience and/or education as determined by the company in lieu of bachelor's degree.
• Preferred
• Bachelor's degree in Science of Nursing or relevant experience

LICENSES or CERTIFICATIONS

Required

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Certified Inpatient Coder (CIC) or Certified Coding Specialist (CCS)

Preferred

• None

Language (Other Than English):

• None

Travel Required:

Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

• Office-Based or Remote Position

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$67,500.00

Pay Range Maximum:

$126,000.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at [email protected]

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Req ID: J273301

If you have questions about this posting, please contact [email protected]