Telecommute Option - Must reside in ID, OR, UT or WA
WHO WE NEED
Payment Integrity Nurse I conducts post service review of claims in prepayment, post payment or audit capacity to ensure appropriate clinical review, reimbursement of claims and accuracy of coding. Applies resources, including but not limited to, internal medical and reimbursement policies and correct coding guidelines based on national standards to support claim review and determination.
Normally to be proficient in the competencies listed above
Payment Integrity Nurse (RN) I would have
Associates or Bachelor's Degree in Healthcare
3 years of experience in a clinical setting, health insurance, coding/claims review, case management
Or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Must have an unrestricted licensure or certification within either OR, WA, ID or UT in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health).
At least 3 years (or full time equivalent) of direct clinical care
Preferred Key Experience:
Register Nurse (RN) license (must have a current unrestricted RN license)
Applies nursing expertise to ensure compliance with medical and reimbursement policies and/or guidelines and accepted standards of care.
Ensures that medical records and other documentation requirements follow federal regulations, company policies and industry standards.
Serves members and providers by performing reviews of claims along with corresponding medical records (when required) to ensure appropriate payment of claims.
Consults with physician advisors to ensure clinically appropriate determinations.
Collaborates with other departments to resolve member or provider claims adjudication issues.
Responds in writing or telephonically to internal and external customers in a professional and diplomatic manner while protecting confidentiality of sensitive documents and issues.
Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established guidelines and timelines.
Assumes responsibility for maintaining clinical competency, for example attending pertinent medical conferences, workshops, and seminars relating to current medical practices, procedures and healthcare industry on at least an annual basis.
Possesses a working knowledge of clinical coding applications, as appropriate.
Participate in courses and continuing education to maintain licensure and applicable certifications.
WHAT YOU BRING:
Knowledge of medical and surgical procedures and other healthcare practices.
Competency to apply clinical expertise to ensure compliance with medical policies and/or reimbursement policies.
Ability to read and interpret medical records and patient data and communicate effectively with clinical and non-clinical staff.
Excellent computer skills and proficiency working software programs (i.e. Microsoft Word, Excel, and PowerPoint); learn new processes and systems quickly.
Strong verbal, written and interpersonal communication and customer service skills.
Ability to work in rapidly changing environment.
Strong research, analytical, math and problem-solving skills.
Ability to work independently; detail-oriented.
Must be able to multi-task and set priorities with minimal supervision.
The expected hiring range for a Payment Integrity Nurse is $73.1k - $98.9k depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 10%. The current full salary range for this role is $68.5k Low Range / $86k MRP / $92.5k High Range.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
medical, dental, and vision coverage for employees and their eligible family members
annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
paid time off varying by role and tenure in addition to 10 company holidays
up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
one-time furniture and equipment allowance for employees working from home
up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.