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Appeals Nurse Analyst

Company: Highmark Medicare Services, Inc.

Location

Job Description:

Highmark Medicare Services, Inc., a Camp Hill, PA based company, is responsible for the combined administration of Medicare Part A and Part B fee-for-service claims for the states of Pennsylvania, Delaware, Maryland, New Jersey and the District of Columbia. Like its parent company, Highmark Inc., Highmark Medicare Services, Inc. embraces workforce diversity as a means to best serve its increasingly diverse customer base. By tapping into the different skills, abilities, and perspectives of a diverse workforce, Highmark Medicare Services, Inc. is able to serve and anticipate the needs of a changing and expanding marketplace. We are currently seeking candidates for the following position in Camp Hill, PA:

APPEALS NURSE ANALYST
This position is responsible for the following: Conducting a review of medical documentation to provide a clinical determination on a Part A and/or Part B case file by applying Medicare coding and policies and rendering a first level appeal decision. This position is located in our Camp Hill department and supports work being conducted in Pittsburgh, Camp Hill and Williamsport units. The position is responsible for rendering a clinical decision based on the Center for Medicare and Medicaid Services (CMS) national requirements, Highmark Medicare Services local policies, Social Security Act and the accepted medical standards of practice. The incumbent will use his/her clinical knowledge along with the Medicare guidelines to render a clinical decision. This is accomplished through working within several computer systems, Standard Medicare Systems (FISS or MCS), an Oracle database (Part A), On-line forms and Lotus Notes; as well as through utilization of advanced computer skills for Internet research and Windows applications. The incumbent is responsible to meet workload expectations as established by management.

Required
A high school diploma or GED. One to three years of experience in clinical decision making. A current LPN or RN license designation.

Preferred
A Bachelors degree in Nursing (BSN) or Business Administration. Certification in in Certified Professional Coder, Certified Professional Utilization.

To submit your resume for consideration, go to the following website: www.highmark.com and click on the Careers link under the About Highmark section of the site. Follow the instructions there to view our current open positions. To apply for this position, use reference #58386. Highmark Medicare Services, Inc., an equal opportunity employer, strives to capitalize on the strengths of individual differences and the advantages of an inclusive workplace. Qualified applicants will receive consideration for employment without regard to race, color, ethnicity, sex, marital status, religion, creed, national origin, disability, veteran’s status, sexual orientation or any other category protected by applicable federal, state or local laws.
 

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