Payment Integrity Nurse Coder RN III

Job Summary

The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and / or coding expertise / judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects. The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development. This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Performs Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements. Audits can include inpatient, outpatient, and professional claims.

Serves cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects.

Serves as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance. Identifies trends and patterns with overall program and individual provider coding practices.

Responsible for training and mentoring Payment Integrity Nurse Coder, RN staff.

Supports the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments of each applicable pipeline opportunity. Works with both internal and external groups to define and develop cost avoidance measures to ensure continued success.

Identifies and defines Payment Integrity issues and reviews and analyzes evidence, utilizes data for the purpose of verifying errors and identifying systemic errors, works as an active team member during scheduled engagements and work collaboratively to achieve the goals of the team, and provides feedback to the team lead on any issues identified during research or claims review.

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s / program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Performs other duties as assigned.

Duties Continued

Education Required

Associate's Degree in Nursing

Education Preferred

Bachelor's Degree in Nursing

Experience

Required :

At least 8 years of clinical RN experience.

At least 3 years of experience in utilization management or clinical coding.

Investigation and / or auditing experience.

Skills

Required :

Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.

Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.

Working knowledge of claims coding and medical terminology.

Solid understanding of standard claims processing systems and claims data analysis.

Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks / demands simultaneously.

Excellent interpersonal, verbal, and written communication skills required with excellent analytical and problem-solving skills. Detail oriented and ability to thrive in fast-paced work environment.

Must be collaborative and have the ability to establish credibility quickly with all levels of management across multiple functional areas and be able to present findings across all departments.

Must be familiar with coordinating benefits between health plan payers.

Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.

Licenses / Certifications Required

Registered Nurse (RN) - Active, current and unrestricted California LicenseCertified Professional Coder (CPC) designation by the American Academy of Professional Codersand / orCertified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).

Licenses / Certifications Preferred

Required Training

Physical Requirements

Light

Additional Information

Salary Range Disclaimer : The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)