Payment Integrity Nurse
Remote within ID, OR, UT, or ID.
Payment Integrity Clinician 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.
- 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.
Normally to be proficient in the competencies listed above
- 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.
Payment Integrity Clinician I would have an Associates or Bachelor's Degree in Healthcare and 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 Registered Nurse license within either OR, WA, ID or UT and at least 3 years (or full time equivalent) of direct clinical care
Additional Preferred Certification: Certified Professional Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA)
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
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 drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com