Company :Highmark Inc.Job Description :
JOB SUMMARY
This job requires the ability to identify issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective claim review with the goal of proper and timely payment to provider and member satisfaction. The incumbent is responsible for the implementation of effective Payment Integrity strategies on a pre-payment and retrospective claims review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate level of payment and resource utilization. It is also used to identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission. The incumbent is expected to utilize specialized skills and knowledge to achieve successful and measurable outcomes. Will monitor and analyze the delivery of health care services in accordance with claims submitted, and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. Will be expected to identify potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit or the Utilization Management area.
ESSENTIAL RESPONSIBILITIES
- Implement the pre-payment and retrospective review processes that are consistent with established industry and corporate standards and are within the Payment Integrity Clinician’s professional discipline. Effectively function in accordance with applicable state, federal laws and regulatory compliance. Implements all reviews according to accepted and established coding criteria, as well as other approved guidelines, payment and medical policies. Promote quality and efficiency in the delivery of review services.
- Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. Practice within the scope of ethical principles.
- Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes. Develop and sustain positive working relationships with internal and external customers.
- Act as a resource and subject matter expert to colleagues with less experience on a frequent basis to problem solve through Payment Integrity Review issues that would be considered of medium to high degree of complexity.
- Ability to visualize, articulate and solve complex problems representative of a broad range of service and claim scenarios.
- Other duties as assigned. Including, but not limited to additional project related responsibilities on a frequent basis that are considered small to medium in nature. Expectation is to drive the assigned project to completion which would include educating the Payment Integrity team. Project assignment is in addition to performing daily Payment Integrity job responsibilities.
EDUCATION
Required
- Associate's Degree in Nursing
Substitutions
- None
Preferred
- Bachelor's Degree in Nursing
EXPERIENCE
Required
- 3 - 5 years of related, progressive experience in a clinical setting
Preferred
- 1-3 years of experience in Managed Care
-
RN’s with CIC coding experience
-
RN's with claims experience.
LICENSES or CERTIFICATIONS
Required
- Registered Nurse
Preferred
- Certified Medical Coder or related
SKILLS
- Demonstrated ability to solve issues that are complex in nature with minimal direction and latitude to proceed on some actions or decisions
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Lifting: up to 10 pounds
Continuously
Lifting: 10 to 25 pounds
Never
Lifting: 25 to 50 pounds
Never
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all 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 all times. In connection with this, all employees must comply 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 all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply 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:
$57,700.00
Pay Range Maximum:
$107,800.00
Base 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 Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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California Consumer Privacy Act Employees, Contractors, and Applicants Notice
What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms.
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 New York, with customers in all 50 states and the District of Columbia.
We passionately serve individual consumers and fellow businesses alike. 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.
We’re also 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.
