Payment Integrity Nurse I

🕒 5 days ago

🥔 Idaho, Oregon, +2 more states – Remote

🥔 Idaho – Remote 🌲 Oregon – Remote ⛷️ Utah – Remote ☕ Washington – Remote

💵 $72k - $117k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Cambia Health Solutions

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare • Healthcare Insurance • Non-profit

Cambia Health Solutions is a nonprofit, mission-driven healthcare company based in Portland, Oregon, that operates consumer-focused health care and health insurance businesses and invests in health innovation. It serves as the parent organization for the Regence family of health plans and runs initiatives and subsidiaries focused on improving care delivery, providing insurance products, and developing digital health tools and services.

📋 Description

• 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 industry on at least an annual basis. • Possesses a working knowledge of clinical coding applications, as appropriate. • Participate in courses and continuing education to maintain licensure and applicable certifications.

🎯 Requirements

• 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, ID, 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)

🏖️ Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits. • Annual employer contribution to a health savings account. • Generous paid time off varying by role and tenure in addition to 10 company-paid holidays. • Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period). • Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave). • Award-winning wellness programs that reward you for participation. • Employee Assistance Fund for those in need. • Commute and parking benefits.