RN Certified Coder Clinical Edit Analyst Job in Detroit, Michigan

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 procedures. 
• Maintain required documentation including logs and databases, Maccess, FACETS entries, Care Advance, letter generation, etc. related to appeals and inquiries as appropriate. 
• Analyze reports, appeals and inquiries related to clinical edits, daily limit processing and other related clinical editing activities.  Resolve issues identified on reports. 
• 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 (NOC). 
• Other duties as assigned.

Qualifications

• 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 analytical skills.
• Excellent communication skills.
• Ability to work as part of a team.
• Ability to work with minimal supervision.
• Proficient in Microsoft Office Suite (Work, Excel, etc.).
• Knowledge of BCN medical management and claims processing workflows, NCQA, CMS and state/federal HMO regulations preferred.

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 disability.