Registered Nurse - Medical Record Claims Auditor Job in Portland, Oregon

Are you excited to step into a complex world that requires a blend of mind, heart and flexibility? We at CareOregon have been strengthening communities since 1994 by making health care work for everyone. As a nonprofit health plan largely focused on Oregon's Medicaid population, we find fulfillment in supporting the underserved.

General Statement of Duties

As a member of the Claims Payment Integrity Team, the Medical Record Claims Auditor is responsible for performing medical record and claims review/audits for Medicare, Medicaid and/or other claims data. This includes pre-payment and post-payment reviews to ensure that proper medical coding guidelines have been followed for claim payment accuracy.

Essential Position Functions

• Conduct internal reviews/audits of medical records and healthcare claims.
• Review medical records to ensure they are complete, accurate and compliant with State/Federal regulations and CareOregon policies.
• Compile, publish and submit detailed reports on audit findings to Cost/Contracting, Utilization and Payment Integrity Decision-makers (CUPID) for approval on post-payment reviews and repayment/recovery process.
• Prepare investigation/audit finding letters to healthcare providers, and respond to provider questions pertaining to the audit findings.
• Analyze claims data to identify trends with potential overpayments, overutilization, fraud, waste and abuse (FWA) and develop reports to support Claims Payment Integrity initiatives and track recoveries/savings.
• Use knowledge of healthcare coding conventions to identify suspicious patterns in medical record documentation.
• Effectively identify and resolve claims issues and determine root causes.
• Develop and enhance documentation and training materials in conjunction with Claims Trainer for claims payment initiatives impacting claim processing procedures.
• Appropriately and correctly adjudicate medical, dental and mental health claims and/or re-adjudicate or adjust/correct claims including some complex and difficult claims, in accordance and/or compliance with plan provisions, State/Federal regulations and CareOregon policies/procedures.
• Review and process repayment/recovery refunds which may result in posting refunds and claim adjustments or re-adjudication.

Education and/or Experience

Required:

• Current unencumbered license as a registered nurse in the State of Oregon
• Bachelor of Science in Nursing
• AAPC or AHIMA certification
• Minimum 2 years’ auditing experience and advanced experience in Evaluation and Management coding or medical claims processing in the health insurance industry
• Minimum 1 year healthcare experience that demonstrates expertise in conducting utilization management (UM)

Preferred

• Minimum 5 years’ clinical experience in primary care and/or specialty clinic practice.
• Preference may be given to qualified candidates who have UM experience administering the Oregon Health Plan (OHP) and the Centers for Medicare and Medicaid Services (CMS) (Medicare) benefits
   

Work Location: Potential to work from home 

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
 

Veterans welcome to apply