Payment Integrity Analyst

Job Description

Job Description

JOB TITLE: PAYMENT INTEGRITY NURSE

DEPARTMENT: CLAIM PAYMENT POLICY

SUMMARY:

The Payment Integrity Nurse is responsible for investigating, reviewing, and applying clinical and/or coding expertise in the development and application of medical and reimbursement policies. The position is also responsible for contributing clinical and coding expertise to various initiatives and projects to include medical cost initiatives.

DUTIES AND RESPONSIBILITIES:

• Develop and maintain claim payment policies that reflect nationally recognized reimbursement practices in accordance with Company benefit, contracting and reimbursement structures, state and federal mandates and other appropriate sources.
• Present Claim Payment Policy Bulletins to appropriate workgroups and committees and revise documents according to recommendations.
• Apply appropriate coding sources to recommend and develop comprehensive code assignments in accordance with established coding guidelines.
• Evaluate and analyze utilization patterns and other sources of information to make recommendations for appropriate and cost-effective utilization.
• Develop business cases to assist with decision making for assigned initiatives.
• Serve as a clinical and coding SME and represent the department in a variety of forums.
• Interact with all levels of associates and management within the Company and with outside contractors, consultants and other organizations.
• Performs additional related duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Bachelor's degree in nursing or equivalent work experience. Licensure required (PA RN license highly preferred).
• A current coding certification (CCS, CPC, RHIA, RHIT).
• Minimum of five years related work experience with evidence of a broad base of clinical knowledge and working knowledge of various medical code sets, including CPT, HCPCS, and ICD-10.
• Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines.
• Familiarity with Medicare rules and regulations.
• Excellent organizational, time management, presentation, verbal, written and analytical skills and demonstrated ability to develop and lead cross-functional teams.
• Must be able to work independently, prioritize workload, meet deadlines, and to assess the criticality of issues.