Integrity Nurse

Payment Integrity Nurse I

Work from home within Oregon, Washington, Idaho, Utah, or North Dakota

Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia's dedicated team of Payment Integrity Nurses are living our mission to make health care easier and lives better. As a member of the Post Service Claim Review team, our Payment Integrity Nurse 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 creating a person-focused health care experience.

Do you believe your clinical expertise could help ensure every health care dollar is spent appropriately and ethically? Would you find purpose in using your nursing knowledge to protect both patients and the integrity of the health care system? Then this role may be the perfect fit.

Qualifications:

• Associates or Bachelor's Degree in Healthcare
• Minimum 3 years of experience in a clinical setting, health insurance, coding/claims review, case management, or equivalent combination of education and experience
• Unrestricted licensure or certification in OR, WA, , or UT in a health or human services discipline that allows independent assessment within scope of practice (medical or behavioral health)
• Minimum 3 years (or full-time equivalent) of direct clinical care experience
• 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 current unrestricted Registered Nurse (RN) license
• Preferred:
  Certified Professional Coder (CPC) certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA)

Skills and Attributes:

• 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.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

• 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.
• Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established guidelines and timelines.
• Assumes responsibility for maintaining clinical competency, for example attending pertinent medical conferences, workshops, and seminars relating to current medical practices, procedures and healthcare…