Integrity Clinician

Company:

Highmark Inc.

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.

• 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.

• Associate’s Degree in Nursing – Required
• Bachelor’s Degree in Nursing – Preferred

• 3–5 years of progressive experience in a clinical setting – Required
• 1–3 years of experience in Managed Care – Preferred

• Registered Nurse – Required
• Certified Medical Coder or related – Preferred

• Demonstrated ability to solve complex issues independently with minimal direction.

0% – 25%

Office‑based; works primarily out of the office. Lifting up to 10 pounds continuously. Rarely travels from the office to various sites.

Minimum: $57,700.00

Maximum: $

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.