DescriptionPosition SummaryRegister Nurse provides clinical and technical analysis for interpretation of appropriate procedural and diagnostic coding and payment of hospital inpatient claims and related inputs. Determines whether facilities are in compliance with industry billing standards. This is a FT WFH role..
Pay Range$78,911.43 - $110,000.00 annually (depending on experience)
*This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.
Please fill out an application on our company page, linked below, to be considered for this position.Benefits:- Medical, Dental, Vision, Pharmacy, Life, & Disability
- 401K- Matching
- FSA
- Employee Assistance Program
- PTO and Company Paid Holidays
Required Skills, Experience & Education:- RN Licensure required, BSN desired.
- 3 - 5 years' experience as a hospital billing coordinator and/or auditor.
- Certified Professional Coder preferred.
- 2 years' health insurance industry experience, with prior experience in auditing hospital claims preferred.
- Prior experience in review of medical records.
- Proficiency with Microsoft Office applications and internet research.
- Strong organizational, analytical and problem-solving skills required.
- Excellent oral and written communications.
- Ability to work well under pressure in a complex and rapidly changing environment.
- Maintain confidentiality and project a professional business appearance.
Primary Functions:- Utilize clinical expertise to identify billing irregularities on hospital bills with appropriate level of review, included but not limited to telephonic discussions and/or letter of findings to the facility citing findings.
- Determine need for claims to be adjudicated with no further review or request records for further review and possible internal audit.
- Perform pre and post pay medical claim reviews utilizing itemized hospital bills and other documentation as needed.
- Assist with specific claim reviews such as diagnosis-related group (DRG) validation, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team.
- Document review findings for processing staff and prepare written communication of findings for hospital representatives.
- Provide advice and recommendations to Clinical Policy unit on proper system coding and editing related to benefits in support of accurate claims payments.
- Collaborate with other Moda areas to provide clinical policy representation at meetings to ensure that decisions which affect claim processing are appropriate and will result in cost effective, efficient, and accurate claims payment.
- Review provider and member complaints and appeals to determine trends and recommend changes for continuous improvement edits related to coding.
- Provide consultation in review of appealed claims requiring interpretation of clinical and pricing documentation (including, but not limited to, operative reports, office notes, and system data).
- Monitor and communicate with contracted vendors that provide services to control claims expenses through negotiation, audits, clinical editing, etc.
- Provide education to employees and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD, HCPCS, etc.
- Performs other related duties and projects assigned.
Contact with Others & Working Conditions: - Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need.
- Internally with various departments. Externally with vendors, group administrators, and providers.
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