Payment Integrity Nurse
Any office location or telecommute within WA, OR, UT, or ID
Bring your experience to a role where you will:
- Conduct post service review of claims in prepayment, post payment or audit capacity to ensure appropriate clinical review, reimbursement of claims and accuracy of coding.
- Apply 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.
At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Collaboration, Innovation, and Accountability. These values are not just words on paper – we live them every day.
Responsibilities & Requirements:
General Functions and Outcomes
- 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.
Competencies and Knowledge:
- Acute inpatient experience preferred.
- 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.
Normally to be proficient in the competencies listed above:
- 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.
- Current unrestricted license as an Registered Nurse within either OR, WA, ID or UT at the time of application submission.
- Certified Professional Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred.
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. We are an equal opportunity 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 is required.
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.