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Nurse Claim Auditor Job in Boston, AA

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Job Title: Nurse Claim Auditor

Employer:Commonwealth Care Alliance
Job Location:Partial Remote
Skills:Auditing,Claims,Coding,Payment Integrity
Preferred Certifications:CPT,HCPCS,ICD10
Required Experience:5 to 7 years
Location:30 Winter St Boston 02108, AA, US
Date Posted:6/23/2021
This position is for a Nurse Claims Auditor for complex medical claims. This role will be instrumental to the Payment Integrity/Claims team.  This role will be responsible for reviewing a wide variety of medical claims to ensure all payment integrity needs are met to ensure payment accuracy. The claims will be Medicare, Medicaid and Mass Health claims. They will act as part of a larger team to share information and collaborate on ongoing efforts to ensure overall payment integrity. This position will report to the Director, Payment Integrity.

What you'll be doing

Conducts claim audits looking for overpayments, including potentially preventable readmissions, unnecessary procedures, excessive units billing and potential fraud waste and abuse.

Perform trend analysis of claims for Payment Integrity and quality assurance.

Work with various other areas within CCA, such as Contracting, FWA and Clinical teams to ensures clarity and accuracy in all phases of the payment integrity claims process.

Responsible for reviewing medical records and claims as needed to ensure payment accuracy, adherence to payment policies, regulations and provider contract obligations.

Ensures optimal system coding that adhere to all billing compliance standards.

Ensures timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements. May require collaboration with internal business partners.

Manages the process for escalated reviews in accordance with Standard Operating Procedures.

Ensures that departmental and organizational policies and procedures as well as regulatory and contractual

requirements and other regulatory reporting needs are met.

What we are looking for

Diploma in Nursing, Associate’s Degree in Nursing, Bachelor's Degree preferred

5+ years clinical/auditing and/or utilization management experience

2+ years’ experience working with a health plan, performing audits to ensure payment integrity is maintained based on appropriate rules, regulations and corresponding contract language.

Registered Nurse licensed in the Commonwealth of Massachusetts in good standing.

Will be required to pass CCA’s credentialing process.

Experience with Dual Eligibility, Medicare, Medicaid and Mass Health.

Knowledge of CPT, ICD10, HCPCS or other coding structures are required.

Knowledge of UB-04s, CMS 1500 forms, and itemized statements

Demonstrated ability to establish and manage performance and outcome metrics.

Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.

Familiarity with InterQual criteria applied to procedures

Understanding of individualized complex care plans

Understands and recognizes medical and insurance terminology

Strong strategic thinker and tactical performer

Strong project management skills with the demonstrated ability to handle multiple projects.

Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies

Proven skills and judgment necessary for independent decision-making.

Excellent organizational, time-management and problem-solving skills

Ability to influence decision making




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