Registered Nurse Quality Review Specialist - CIC or CCS

Highmark Health

5d • $67,500 - $126,000 • Remote

About The Position

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.

Requirements

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

Nice To Haves

• 3 years of experience with electronic health systems
• Bachelor’s degree in Science of Nursing or relevant experience
• None

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees