Integrity Clinician

Company

Highmark Inc.

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 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 healthcare services in accordance with claims submitted, and analyze 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.

• 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, and 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.

Required: Associate's Degree in Nursing

None

Bachelor's Degree in Nursing

Required: 3–5 years of related, progressive experience in a clinical setting

Preferred: 1–3 years of experience in Managed Care

Required: Registered Nurse

Preferred: Certified Medical Coder or related

• Demonstrated ability to solve issues that are complex in nature with minimal direction and latitude to proceed on some actions or decisions

None

0% - 25%

Lifting: up to 10 pounds

Lifting: 10 to 25 pounds

Lifting: 25 to 50 pounds

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

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…