Payment Integrity RN

PAYMENT INTEGRITY RN (HEALTHCARE) Work from home (telecommute) within Oregon, Washington, Idaho or Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system. Who We Are Looking For: Every day, Cambia’s Clinical Audit Team is living our mission to make health care easier and lives better. Payment Integrity Clinician 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 experienced RN with Claims or Reimbursement experience looking to make a difference in the healthcare industry, apply for this exciting opportunity today! What You Bring to Cambia: Preferred Key Experience: Experience with Government Programs such as FEP and Medicare Reimbursement Policy Claims Clinical Auditor or reviewer Qualifications and Certifications: Associates or Bachelor's Degree in Healthcare, or related fields 3 years of experience in a clinical setting, health insurance, coding/claims review, case management Equivalent combination of education and experience 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. 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 $85k–$95k, depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 10%.  The current full salary range for this position is $78k Low/ $89k MRP / $116k High About Cambia Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100 year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through. Why Join the Cambia Team? At Cambia, you can: Work alongside diverse teams building cutting-edge solutions to transform health care. Earn a competitive salary and enjoy generous benefits while doing work that changes lives. Grow your career with a company committed to helping you succeed. Give back to your community by participating in Cambia-supported outreach programs. Connect with colleagues who share similar interests and backgrounds through our employee resource groups. We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more. In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include: 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. Learn more about our benefits. We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb. We are an Equal Opportunity employer dedicated to 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 background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. Everyone is a health care consumer deserving of a simpler, more personalized experience. Cambia is transforming the health care system to revolve around people. For over 100 years we’ve designed people-first health solutions rooted in the nation’s first health plan, a loggers’ wage pool established in the Pacific Northwest. Today that pioneering spirit aligns our family of over 20 companies, including 4 not-for-profit BlueCross and BlueShield licensed health plans serving over 3 million Americans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices. Interested in driving accessibility, affordability and quality health care for real people? Apply to any of our open jobs or join the Twitter conversation @Cambia. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.

Salary : $85,000 - $95,000