Registered Nurse Quality Review Specialist - CIC or CCS

A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best. Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia, and eastern and northwestern New York with customers in 50 states and the District of Columbia. We passionately serve individual consumers and fellow businesses alike. And our companies cover a diversified spectrum of essential health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions. Our financial position reflects strength and stability, with our year-end 2020 consolidated revenues totaling $18 billion. And we’re proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day

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.

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.