[Hiring] Registered Nurse Quality Review Specialist - CIC or CCS @Highmark Health

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.

Role Description

This role involves an in-depth review of provider submitted appeals of medical claims, that have been previously 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.
• 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 processes 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

Qualifications
• 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

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

Licenses or Certifications
• 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)

Travel Required
• Less than 25%

Physical, Mental Demands and Working Conditions
• Position Type: Office-Based or Remote Position

Apply Now

Apply Now