RN Clinical Edit Analyst

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: analysis,process,medical,solutions,quality assurance,assist,analysis,experience,license,teamwork,management,professional,knowledge


Competitive Total Compensation Package

Overview: Review all appeals focused on medical necessity including review of all documentation, contact with providers, interaction with related corporate departments such as medical directors and other follow-up activities.
Responsibilities: <ul> <li>Process appeal requests related to clinical editing based on medical necessity; handle resolution of other clinical edits such as multi-surgery, daily limit processing, member eligibility, verification of claim validity, submission of required documentation and appeal timeframes in accordance with departmental procedures.</li> <li>Maintain required documentation including logs and databases, Macess, FACETS entries, Care Advance, letter generation, etc. related to appeals and inquiries as appropriate.</li> <li>Analyze reports, appeals and inquiries related to clinical edits, daily limit processing and other related clinical editing activities. Resolve issues identified on reports.</li> <li>Coordinate with medical consultants to resolve appeals that require their intervention; document resolution in accordance with established processes.</li> <li>Resolve internal inquiries to ensure consistent application of clinical editing criteria.</li> <li>Assist in resolution of other coding, clinical editing and policy related issues, including but not limited to review of cases submitted with not otherwise classified codes (NOC).</li> <li>Other duties as assigned.</li> </ul>
Requirements: <div class="job-details__section"> <div class="basic-formatter" data-bind="html: job().description"> <p>QUALIFICATIONS</p> <ul> <li>Current valid and unrestricted Michigan RN license. BSN preferred.</li> <li>Certified professional coder designation (for example CPC)</li> <li>Five (5) years clinical experience in a health care setting as a practicing registered nurse.</li> <li>Two (2) years&rsquo; coding, billing, or auditing/record review experience as a professional coder.</li> <li>Excellent problem solving and analytical skills.</li> <li>Excellent communication skills.</li> <li>Ability to work as part of a team.</li> <li>Ability to work with minimal supervision.</li> <li>Proficient in Microsoft Office Suite (Work, Excel, etc.).</li> <li>Knowledge of BCN medical management and claims processing workflows, NCQA, CMS and state/federal HMO regulations preferred.</li> </ul> </div> </div> <div class="job-details__apply">&nbsp;</div>