|Employer:||Blue Cross Blue Shield of Michigan
|Type:||FULL TIME, OTHER
|Required Certifications:||Certified professional coder designation (for example CPC)
|Location:|| Detroit 48226, MI, US
RN Certified Coder
Clinical Edit Analyst
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.
- 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
- Maintain required documentation
including logs and databases, Maccess, FACETS entries, Care Advance,
letter generation, etc. related to appeals and inquiries as
- Analyze reports, appeals and
inquiries related to clinical edits, daily limit processing and other
related clinical editing activities. Resolve issues identified on
- Coordinate with medical
consultants to resolve appeals that require their intervention, document
resolution in accordance with established processes.
- Resolve internal inquiries to
ensure consistent application of clinical editing criteria.
- 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
- Other duties as assigned.
- Current valid and unrestricted
Michigan RN license. BSN preferred.
- Certified professional coder
designation (for example CPC)
- Five (5) years clinical
experience in a health care setting as a practicing registered nurse.
- Two (2) years' coding, billing,
or auditing/record review experience as a professional coder.
- Excellent problem solving and
- Excellent communication skills.
- Ability to work as part of a
- Ability to work with minimal
- Proficient in Microsoft Office
Suite (Work, Excel, etc.).
- Knowledge of BCN medical management
and claims processing workflows, NCQA, CMS and state/federal HMO
All qualified applicants will receive
consideration for employment without regard to, among other grounds, race,
color, religion, sex, national origin, sexual orientation, age, gender
identity, protected veteran status or status as an individual with a