Clinical Specialist Jobs in Pittsburgh, PA

About The Position

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 billed 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 (NCDs), Local Coverage Determinations (LCDs), AMA guidance, and other regulatory requirements.
• Lead coding review activities for new claim edit implementation, 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 analysis to management and senior leadership.