Payment Integrity Nurse Coder RN III

• 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
• Serving 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
• Providing guidance related to Payment Integrity initiatives to include concept and cost avoidance development
• Training and mentoring Payment Integrity Nurse Coder, RN staff
• Acting as a Subject Matter Expert, serving as a resource and mentor for other staff
• Performing Quality Audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements
• Serving cross functionally with Utilization Management, Medical Directors, and other internal teams to assist in identification of overpayments as well as other projects
• Serving as SME for all Payment Integrity functions to include both Retrospective Data Mining as well as Pre-Payment Cost Avoidance
• Identifying trends and patterns with overall program and individual provider coding practices
• Supporting the creation and execution of strategies that determine impact of opportunity and recover overpayments as well as prospective internal controls preventing future overpayments
• Identifying and defining Payment Integrity issues and reviews and analyzing evidence, utilizing data for the purpose of verifying errors and identifying systemic errors
• Applying subject expertise in evaluating business operations and processes
• Identifying areas where technical solutions would improve business performance
• Consulting across business operations, providing mentorship, and contributing specialized knowledge
• Ensuring 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
• Providing training, recommending process improvements, and mentoring junior level staff, department interns, etc. as needed

• Associate's Degree in Nursing
• 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
• 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
• Must be familiar with coordinating benefits between health plan payers
• Advanced knowledge of Microsoft Office suite, including Word, Excel and PowerPoint
• Registered Nurse (RN) - Active, current and unrestricted California License
• Certified Professional Coder (CPC) designation by the American Academy of Professional Coders and/or Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA)

Bachelor's Degree in Nursing

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