Payment Review Nurse
Payment Review Nurse or Senior DOE
Salt Lake City, UT; Lewiston, ID; Burlington, WA; Seattle, WA; Tacoma, WA; Portland, OR; Medford, OR; Salem OR; Telecommute within WA, OR, ID, and UT.
Bring your experience to a role where you will:
- Conducts post service review of claims in prepayment, post payment or audit capacity to ensure appropriate payment of claims and accuracy of coding.
- Review medical records, internal policies and resources.
- Apply policy and correct coding guidelines based on national standards to support claim review.
Responsibilities & Requirements
At Cambia, our values are fundamental to achieving our Cause of transforming the health care industry. They guide our actions and bring diverse perspectives together to improve the health care journey better for those we serve. All eight values are equally important and linked to the others: Empathy, Hope, Courage, Trust, Commitment, Innovation, and Accountability. These values are not just words on paper - we live them every day.
- Payment Review Clinician would have an Associates or Bachelor’s degree in Nursing or health-related field and 3+ years of experience in auditing or retrospective review or equivalent combination of education and experience.
- Extensive knowledge of medical claim coding and/or claim review is required.
- Proven knowledge of medical and surgical procedures and other healthcare practices and trends.
- Excellent computer skills and proficiency working software programs (e.g., Microsoft Word and Excel, Outlook, and database query tools). Ability to function efficiently in multiple claim systems.
- Math aptitude and analytical ability
- Strong verbal, written and interpersonal communication and customer service skills.
- Demonstrated ability to perform and understand complex and detailed work with accuracy and minimum supervision.
- Basic understanding of member contract benefits. Ability to interpret policies and procedures and communicate complex topics effectively.
- Ability to think critically and make decisions within individual role and responsibility
Additional Minimum Requirements for Senior level
- Payment Review Clinician Senior would have an Associates or Bachelor’s degree in Nursing or related field and 5+ years of experience in auditing or retrospective review or equivalent combination of education and experience.
- Advanced level of understanding of member contract benefits.
- Strong knowledge of department operations and able to serve as Subject Matter Expert for all review activities
Required Licenses, Certifications, Registration, Etc.
- Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care
Must have at least one of the following:
- Bachelor’s degree (or higher) in a health or human services-related field (psychiatric RN or Masters’ degree in Behavioral Health preferred for behavioral health); or
- Register Nurse (RN) license (must have a current unrestricted RN license for medical care management)
- Certified Professional Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred
General Functions and Outcomes
- Applies clinical expertise and judgment to ensure compliance with policy, guidelines, and accepted standards of care. Practices within the scope of their license. Uses national guidelines for facility based level of care criteria.
- Serves members and providers primarily through a) performing review or auditing of claims submitted along with medical records (when required) to ensure appropriate payment of claims b) applying policy and procedures when evaluating billing and clinical information.
- Performs all aspects of audit, claim review, and appeal work proficiently, regardless of claims processing system assigned.
- Consults with physician advisors to ensure clinically appropriate determinations.
- Assists Supervisor or Manager with problem identification and resolution by researching and reporting problem areas. Identifies provider billing problems and deviations from normal practice patterns. Recommends resolution or makes appropriate referral (Ex: to Fraud and Abuse Department or Supervisor)
- Collaborates with other departments to resolve claims adjudication, quality of care, member or provider issues.
- Responds in writing or telephonically to internal and external customers in a professional and diplomatic manner while protecting confidentiality of sensitive documents and issues.
- Operations – performs initial review and screening of claims routed based on edits or other triggers making determinations or recommendations.
- Reviews edit reporting for accurate and appropriate adjudication in accordance with Nurse Guidelines.
- Possesses a working knowledge of clinical coding applications.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members more than 90 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you’re seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers’ engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
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Cambia Health Solutions, headquartered in Portland, Oregon, is dedicated to transforming health care. We put people at the heart of everything we do as we work to make the health care system better and more economically sustainable for people and their families. Our company reaches more than 70 [...]