Payment Integrity Nurse I

🕒 vor 15 Tagen

🥔 Idaho, Oregon, +2 weitere Bundesländer – Remote

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

💵 $72.000 - $117.000 / Jahr

⏰ Vollzeit

🟡 Mittelstufe

🟠 Senior

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Cambia Health Solutions

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5001 - 10000 Mitarbeiter

🏥 Gesundheitswesen

⚕️ Krankenversicherung

🤝 Non-Profit

Healthcare • Healthcare Insurance • Non-profit

Cambia Health Solutions ist ein gemeinnütziges, missionsorientiertes Gesundheitsunternehmen mit Sitz in Portland, Oregon, das verbraucherorientierte Gesundheits- und Krankenversicherungsunternehmen betreibt und in Gesundheitsinnovationen investiert. Es dient als Mutterorganisation für die Regence-Familie von Gesundheitsplänen und führt Initiativen und Tochtergesellschaften, die sich auf die Verbesserung der Pflegebereitstellung, die Bereitstellung von Versicherungsprodukten und die Entwicklung digitaler Gesundheitswerkzeuge und -dienste konzentrieren.

Beschreibung

• 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.

🎯 Anforderungen

• 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)

🏖️ Vorteile

• 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.