Clinical Claim Editing Specialist (Registered Nurse)

UPMC•Pittsburgh, PA

1d•Hybrid

About The Position

UPMC Health Plan is hiring a Clinical Claim Editing Specialist in the Claim Operations Coding department. This full-time hybrid position is based in the Pittsburgh area; work is primarily remote, with occasional office attendance depending on departmental needs. The specialist serves as the Claim Editing team’s clinical and coding subject matter expert, responsible for clinical coding review, analysis, development, implementation, validation, and ongoing monitoring of claims payment edits and reimbursement policy rules. The role combines clinical knowledge, coding expertise, claims analysis, and payment integrity principles to ensure claim editing is clinically appropriate, operationally effective, financially sound, and compliant with regulatory and industry standards. The specialist collaborates with external payment integrity vendors and internal stakeholders to develop, evaluate, and optimize claims editing solutions across all lines of business. The role interprets medical records, coding guidelines, reimbursement policies, and regulatory requirements to support claim-editing strategies, and advises leadership on complex claims, coding issues, edit performance, provider disputes, and reimbursement policy initiatives.

Requirements

Bachelor of Science in Nursing (BSN) and four years of relevant payment integrity experience, or an Associate Degree in Nursing (ADN) and six years of payment integrity experience.
AAPC or AHIMA professional coding certification, such as CPC, CPMA, CIC, CCA, CCS, or CCS-P.
Four years of clinical healthcare experience.
Four or more years of experience in payment integrity, claim editing, fraud, waste, and abuse, coding review, clinical auditing, or closely related healthcare payer functions.
Advanced knowledge of medical terminology, clinical documentation, reimbursement methodologies, and healthcare regulatory requirements.
In-depth knowledge of ICD-10, CPT, HCPCS, modifier usage, NCCI edits, and industry coding standards.
Ability to analyze medical records and determine coding and reimbursement appropriateness.
Strong analytical, problem-solving, and investigative skills.
Proficiency with Microsoft Excel and reporting tools.
Excellent written and verbal communication skills.

Nice To Haves

Registered Nurse (RN) license in good standing.
Master's degree in Nursing, Health Administration, Business, Healthcare Informatics, or a related field.
Two or more years of professional medical coding experience in a clinical setting.
Experience with payment accuracy vendors, claim-editing software platforms, and healthcare data analysis tools.
Experience configuring, testing, monitoring, and validating healthcare claim-editing software.
Experience developing, validating, implementing, and monitoring custom claim-editing logic and reimbursement rules within a healthcare payer environment.

Responsibilities

Serve as the primary clinical and coding subject matter expert for the Claim Editing team.
Provide clinical interpretation and coding expertise related to CPT, HCPCS, ICD-10-CM, ICD-10-PCS, modifier usage, and other industry-standard coding methodologies.
Review medical records, claims data, provider documentation, and supporting clinical information to determine whether services are appropriately documented, coded, and reimbursable.
Evaluate the clinical appropriateness and coding logic of proposed claim edits, vendor recommendations, and reimbursement policies.
Provide clinical and coding guidance for complex claims, appeals, provider inquiries, and reimbursement disputes.
Research and interpret Medicare guidance, National Coverage Determinations, Local Coverage Determinations, AMA guidance, and other regulatory requirements.
Lead coding reviews for new claim-edit implementations, edit modifications, and vendor-supplied content updates.
Investigate edit performance issues, validate outcomes, identify root causes, and recommend corrective actions.
Ensure claim-edit customizations align with organizational reimbursement strategies and business objectives across applicable lines of business.
Support implementation, testing, validation, monitoring, and maintenance of claims payment edits.
Identify opportunities to improve payment accuracy through clinical review, coding analysis, and claim-editing enhancements.
Assist with developing and revising reimbursement policies, editing standards, workflows, and best practices.
Analyze claims, edit performance, denial patterns, provider billing trends, and reimbursement outcomes.
Identify trends, risks, coding opportunities, and areas requiring clinical or operational intervention.
Present findings, recommendations, and financial impact analyses to management and senior leadership.