Payment Integrity RN - Cambia Health Solutions, Inc

PAYMENT INTEGRITY RN (I) (Clinician) (HEALTHCARE)

Work from home (telecommute) within Oregon, Washington, Idaho or Utah

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Who We Are Looking For:

Every day, Cambia's dedicated Clinical Audit team is living our mission to make health care easier and lives better. As a member of the Clinical Audit team, the Payment Integrity RN (I) conducts post service review of claims in prepayment, post payment or audit capacity to ensure appropriate clinical review, reimbursement of claims and accuracy of coding. Applies resources, including but not limited to, internal medical and reimbursement policies and correct coding guidelines based on national standards to support claim review and determination. - all in service of making our members' health journeys easier.

If you're a motivated and detail-oriented clinician looking to make a difference in payment integrity, apply for this exciting opportunity today!

What You Bring to Cambia:

PREFERRED KEY EXPERIENCE:

• At least 5 years of clinical (as an RN) experience at an acute inpatient hospital

• Exceptional Critical Thinking Skills

• Truly adapts to change

• An RN who will speak up with questions, concerns but is not afraid to & is able to work independently as well as a team player

• Tech savvy (not expert) - CRRT uses multiple applications throughout out the day & the PICs are required to be able to do so without hesitation

Qualifications:

• Must have an unrestricted licensure or certification within either OR, WA, ID or UT 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

• Register Nurse (RN) license (must have a current unrestricted RN license).

Skills and Attributes (Not limited to):

• Knowledge of medical and surgical procedures and other healthcare practices.

• Competency to apply clinical expertise to ensure compliance with medical policies and/or reimbursement policies.

• Ability to read and interpret medical records and patient data and communicate effectively with clinical and non-clinical staff.

• Excellent computer skills and proficiency working software programs (i.e. Microsoft Word, Excel, and PowerPoint); learn new processes and systems quickly.

• Strong verbal, written and interpersonal communication and customer service skills.

• Ability to work in rapidly changing environment.

• Strong research, analytical, math and problem-solving skills.

• Ability to work independently; detail-oriented.

• Must be able to multi-task and set priorities with minimal supervision.

What You Will Do at Cambia (Not limited to):

• Applies nursing expertise to ensure compliance with medical and reimbursement policies and/or guidelines and accepted standards of care.

• Ensures that medical records and other documentation requirements follow federal regulations, company policies and industry standards.

• Serves members and providers by performing reviews of claims along with corresponding medical records (when required) to ensure appropriate payment of claims.

• Consults with physician advisors to ensure clinically appropriate determinations.

• Collaborates with other departments to resolve member or provider claims adjudication 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.

The expected hiring range for the Payment Integrity RN is 80k - 85k annually depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $70k Low Range / $88k MRP / $115k High Range.