Hybrid Clinical Claim Editing Lead

UPMC; Pittsburgh (Allegheny County); Hybrid; USD 90,000 - 120,000; Full time

Job summary

UPMC Health Plan in the Pittsburgh area is seeking a Clinical Claim Editing Specialist for a full-time hybrid role. The specialist will serve as the clinical and coding SME for claims edits, interpreting CPT/HCPCS/ICD-10-CM, and ensuring edits align with reimbursement policies and regulatory requirements.

Responsibilities include leading edit implementations, analyzing denial patterns, and collaborating with vendors and internal stakeholders to optimize payment integrity across lines of

Qualifications

• BSN with four years of payment integrity experience or ADN with six years.
• CPC, CPMA, CIC, CCA, CCS, or CCS-P certification.
• Four years of clinical healthcare experience.
• Four+ years in payment integrity, claim editing, or related payer functions.
• Advanced knowledge of ICD-10, CPT, HCPCS and regulatory requirements.
• Strong analytical and communication skills.
• Proficiency with Excel and reporting tools.

Responsibilities

• Serve as the primary clinical and coding SME for Claim Editing team.
• Provide clinical interpretation and coding expertise related to CPT, HCPCS, ICD-10-CM, ICD-10-PCS, modifier usage, and other coding methodologies.
• Review medical records, claims data, provider documentation to determine reimbursement.
• Evaluate clinical appropriateness and coding logic of edits and policies.
• Provide guidance for complex claims, appeals, provider inquiries, and disputes.
• Research Medicare guidance, NCDs, LCDs, AMA guidance, and regulatory requirements.
• Lead coding review activities for new edit implementations and updates.
• Investigate edit performance, identify root causes, and recommend actions.
• Ensure edits align with reimbursement strategies across lines of business.
• Support testing, validation, monitoring, and maintenance of edits.
• Identify opportunities to improve payment accuracy via review and enhancements.
• Assist in developing and revising reimbursement policies and workflows.
• Analyze claims, edit performance, denial patterns, and provider trends.
• Present findings and financial impact to management.

Skills

Analytical skills

Problem-solving

Attention to detail

Communication skills

Clinical interpretation

Healthcare payer domain knowledge

Education

BSN degree

ADN degree with required experience

RN license

CPC/CPMA/CIC/CCA/CCS/CCS-P certification

Tools

Excel

Reporting tools

Job description

UPMC Health Plan in the Pittsburgh area is seeking a Clinical Claim Editing Specialist for a full-time hybrid role. The specialist will serve as the clinical and coding SME for claims edits, interpreting CPT/HCPCS/ICD-10-CM, and ensuring edits align with reimbursement policies and regulatory requirements.

Responsibilities include leading edit implementations, analyzing denial patterns, and collaborating with vendors and internal stakeholders to optimize payment integrity across lines of