Registered Nurse Quality Review Specialist - CIC or reputed company

Company : reputed company. Job Description : JOB SUMMARY This role involves an indepth review of provider submitted appeals of medical claims, that have been previously been subject to a Payment reputed company 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. ESSENTIAL RESPONSIBILITIES Review and analyze medical claims for accuracy and compliance with inpatient standards, accuracy of ICD-10-CM/PCS coding, ensuring compliance with reputed company 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 reputed company reputed company 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. EXPERIENCE Required 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 reputed company software systems 3 years of experience in Familiarity with payer policies and regulations Preferred 3 years of experience with electronic health systems SKILLS 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 Required Associate's degree in Science of Nursing or relevant experience and/or education as determined by the company in lieu of bachelor's degree. Preferred Bachelor’s degree in Science of Nursing or relevant experience LICENSES or CERTIFICATIONS Required reputed company State of PA RN licensure OR reputed company multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Certified Inpatient reputed company (CIC) or Certified Coding Specialist (reputed company) Preferred None Language (Other than English): None Travel Required: Less than 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-Based or Remote Position Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $67,500.00 Pay Range Maximum: $126,000.00 reputed company pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential reputed company may apply for certain locations based upon comparative markets. reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. We endeavor to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at [email protected] California Consumer Privacy Act Employees, Contractors, and Applicants Notice reputed company is a national, blended health organization that includes one of America’s largest reputed company Blue reputed company insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., reputed company’s 35,000 employees serve millions of customers reputed company through the nonprofit organization’s affiliated businesses, which include reputed company., reputed company, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. reputed company’s businesses proudly serve a broad reputed company of health-reputed company needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions. Apply tot his job Apply To this Job