Highmark Health
Company:
Highmark Inc.
Job Summary This position requires the ability to identify issues related to provider claims data, including determining the appropriateness of code submission, analyzing claim rejections, and completing retrospective claim reviews to ensure timely payment and member satisfaction. The incumbent will implement Payment Integrity strategies for pre‑payment and retrospective claims reviews, analyze medical documentation and claims data, and provide education to network providers on proper billing practices.
Essential Responsibilities
Implement pre‑payment and retrospective review processes that meet industry and corporate standards, ensuring compliance with state, federal laws, and payment policies.
Respect member privacy, sharing only information relevant to care within applicable legal frameworks.
Identify education opportunities for professional and facility providers to improve processes and build positive working relationships with internal and external customers.
Act as a subject‑matter expert, mentoring colleagues on medium to high complexity Payment Integrity review issues.
Visualize, articulate, and solve complex claim scenarios across a broad range of service cases.
Perform additional project‑related duties as assigned, driving projects to completion and educating the Payment Integrity team.
Education
Associate’s Degree in Nursing – Required
Bachelor’s Degree in Nursing – Preferred
Experience
3–5 years of progressive experience in a clinical setting – Required
1–3 years of experience in Managed Care – Preferred
Licenses or Certifications
Registered Nurse – Required
Certified Medical Coder or related – Preferred
Skills
Demonstrated ability to solve complex issues independently with minimal direction.
Travel Requirement 0% – 25%
Physical, Mental Demands and Working Conditions Office‑based; works primarily out of the office. Lifting up to 10 pounds continuously. Rarely travels from the office to various sites.
Pay Range Minimum: $57,700.00
Maximum: $107,800.00
EEO Statement 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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Highmark Inc.
Job Summary This position requires the ability to identify issues related to provider claims data, including determining the appropriateness of code submission, analyzing claim rejections, and completing retrospective claim reviews to ensure timely payment and member satisfaction. The incumbent will implement Payment Integrity strategies for pre‑payment and retrospective claims reviews, analyze medical documentation and claims data, and provide education to network providers on proper billing practices.
Essential Responsibilities
Implement pre‑payment and retrospective review processes that meet industry and corporate standards, ensuring compliance with state, federal laws, and payment policies.
Respect member privacy, sharing only information relevant to care within applicable legal frameworks.
Identify education opportunities for professional and facility providers to improve processes and build positive working relationships with internal and external customers.
Act as a subject‑matter expert, mentoring colleagues on medium to high complexity Payment Integrity review issues.
Visualize, articulate, and solve complex claim scenarios across a broad range of service cases.
Perform additional project‑related duties as assigned, driving projects to completion and educating the Payment Integrity team.
Education
Associate’s Degree in Nursing – Required
Bachelor’s Degree in Nursing – Preferred
Experience
3–5 years of progressive experience in a clinical setting – Required
1–3 years of experience in Managed Care – Preferred
Licenses or Certifications
Registered Nurse – Required
Certified Medical Coder or related – Preferred
Skills
Demonstrated ability to solve complex issues independently with minimal direction.
Travel Requirement 0% – 25%
Physical, Mental Demands and Working Conditions Office‑based; works primarily out of the office. Lifting up to 10 pounds continuously. Rarely travels from the office to various sites.
Pay Range Minimum: $57,700.00
Maximum: $107,800.00
EEO Statement 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.
#J-18808-Ljbffr