Clinical Claim Editing Specialist (Registered Nurse)

UPMC Health Plan has an exciting opportunity for a Clinical Claim Editing Specialist position in the Claim Operations Coding department. This is a full-time hybrid position based in the Pittsburgh area. While you'll primarily work remotely, you'll come into the office occasionally depending on departmental needs. The Clinical Claim Editing Specialist serves as the department's clinical and coding subject matter expert and is responsible for the clinical coding review, analysis, development, implementation, validation, and ongoing monitoring of claims payment edits and reimbursement policy rules.

The Clinical Claim Editing Specialist combines advanced clinical knowledge, coding expertise, claims analysis, and payment integrity principles to ensure that claim editing activities are clinically appropriate, operationally effective, financially sound, and compliant with regulatory and industry standards.

The position collaborates with external payment integrity vendors and internal stakeholders to develop, evaluate, and optimize claims editing solutions across all lines of business.

This role provides clinical interpretation of medical records, coding guidelines, reimbursement policies, and regulatory requirements to support the development and maintenance of claim editing strategies.

The position also serves as a resource for leadership regarding complex claims, coding issues, edit performance concerns, provider disputes, and reimbursement policy initiatives.

Responsibilities:

Clinical and Coding

• Serve as the primary clinical and coding subject matter expert for Claim Editing team.

• Provide clinical interpretation and coding expertise related to CPT, HCPCS, ICD-10-CM, ICD-10-PCS, modifier usage, and other industry-standard coding methodologies.

• Review medical records, claims data, provider documentation, and supporting clinical information to determine whether billed services are appropriately documented, coded, and reimbursable.

• Evaluate the clinical appropriateness and coding logic of proposed claim edits, vendor recommendations, and reimbursement policies.

• Provide clinical and coding guidance for complex claims, appeals, provider inquiries, and reimbursement disputes.

• Research and interpret applicable Medicare guidance, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), AMA guidance, and other regulatory requirements.

Claim Editing and Payment Integrity

• Lead coding review activities associated with new claim edit implementation, edit modifications, and vendor-supplied content updates.

• Investigate edit performance issues, validate outcomes, identify root causes, and recommend corrective actions.

• Ensure claim edit customizations align with organizational reimbursement strategies and business objectives across all applicable lines of business.

• Support implementation, testing, validation, monitoring, and maintenance of claims payment edits.

• Identify opportunities to improve payment accuracy through clinical review, coding analysis, and claim editing enhancements.

• Assist with the development and revision of reimbursement policies, editing standards, workflows, and best practices.

Analytics and Reporting

• Analyze claims, edit performance, denial patterns, provider billing trends, and reimbursement outcomes.

• Identify trends, risks, coding opportunities, and areas requiring clinical or operational intervention.

• Present findings, recommendations, and financial impact analysis to management and senior leadership.

Required

• Bachelor of Science in Nursing (BSN) degree and four years of relevant payment integrity experience OR Associate Degree in Nursing (ADN) and six years of payment integrity experience

• AAPC or AHIMA professional coding certification (CPC, CPMA, CIC, CCA, CCS, CCS-P)

• Four years of clinical healthcare experience.

• Four or more years of experience in payment integrity, claim editing, fraud, waste, and abuse, coding review, clinical auditing, or closely related healthcare payer functions.

• Advanced knowledge of medical terminology, clinical documentation, reimbursement methodologies, and healthcare regulatory requirements.

• In-depth knowledge of ICD-10, CPT, HCPCS, modifier usage, NCCI edits, and industry coding standards.

• Ability to analyze medical records and determine coding and reimbursement appropriateness.

• Strong analytical, problem-solving, and investigative skills.

• Proficiency with Microsoft Excel and reporting tools.

• Excellent written and verbal communication skills.

Preferred

• Registered Nurse (RN) license in good standing.

• Master's degree in Nursing, Health Administration, Business, Healthcare Informatics, or related field.

• 2+ years professional medical coding experience in a clinical setting

• Experience with payment accuracy vendors, claim editing software platforms, and healthcare data analysis tools

• Experience configuring, testing, monitoring, and validating healthcare claim editing software

• Experience developing, validating, implementing, and monitoring custom claim editing logic and reimbursement rules within a healthcare payer environment.Licensure, Certifications, and Clearances:

• Act 34UPMC is an Equal Opportunity Employer/Disability/Veteran