The Payment Integrity Nurse Coder 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 will serve 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 will also be responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development
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.
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.
Perform other duties as assigned.
Associate's Degree or Bachelor's Degree
RN or PA with a minimum of Five (5) years clinical experience and a minimum of two (2) years in utilization management or clinical coding.
LPN with a minimum of five (6) years clinical experience and a minimum of three (3) years in utilization management or clinical coding.
Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.
Investigation and/or auditing experience
Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.
Excellent written and analytical skills. Detail oriented and ability to thrive in fast-paced work environment.
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.
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.
Current and unrestricted CA RN License
Certified Professional Coder (CPC)
A current Certified Professional Coder (CPC) designation by the American Academy of Professional Coders or a current Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).