Payment Integrity RN

Bcbsla; United States; Remote; USD 70,000 - 95,000; Full time

Job summary

BCBSLA is seeking a Nurse Auditor to ensure accurate medical coding, billing practices, and compliance with reimbursement rules. The role requires RN licensure and at least 2 years of clinical experience, with familiarity of CMS/DOI regulations and coding guidelines. Travel may be required.

The position reports to the Manager, Payment Integrity, Clinical, and involves collaboration with providers, physicians, and internal teams in a busy health plan environment in Louisiana.

Qualifications

• Bachelor’s Degree in Nursing or RN Certification required.
• 2 years of RN experience required.
• Experience with provider billing practices and coding guidelines preferred.

Responsibilities

• Audit providers to ensure correct medical coding and billing practices.
• Resolve CPT/ICD9 reimbursement and coding inquiries for internal and external requests.
• Identify provider reimbursement problems and recommend corrective action.
• Maintain understanding of coding guidelines and billing systems.
• Travel overnight up to one week as needed.

Skills

Disease processes knowledge

Audit skills

Communication skills

Analytical skills

Travel readiness

Word/Excel proficiency

Education

Bachelor’s Degree in Nursing

RN Licensure (Louisiana)

Compact State Licensure

Tools

Word

Excel

Job description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.

Residency in or relocation to Louisiana is preferred for all positions.

Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.

POSITION PURPOSE

This position is responsible for auditing providers to ensure correct medical coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments. Additionally, this position is responsible for complying with all laws and regulations that are associated with duties and responsibilities.

NATURE AND SCOPE

• This role does not manage people
• This role reports to this job: MANAGER, PAYMENT INTEGRITY, CLINICAL
• Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with:

All levels of BCBSLA personnel; other insurance carriers, agencies and professional organizations; other Blue Cross Plans; physicians and their office personnel; hospital and allied provider administration and personnel; Blue Cross subscribers; medical/surgical suppliers; attorneys; medical specialty organizations (i.e. American College of Obstetric and Gynecology); national medical coding associations (i.e. American Academy of Professional Coders, AHIMA, AMA); Blue Cross Association and CMS (Medicare).

QUALIFICATIONS

Education

• Bachelor’s Degree in Nursing or RN Certification required
  Work Experience
• 2 years of experience as an RN required
• Experience in multi-speciality setting preferred
• Experience with provider billing practices, American Medical Association coding guidelines, Correct Coding Initiative edits, Physician Specialty guidelines, BCBSLA reimbursement programs, provider agreements, claims adjudication processes, and regulatory agency policies (CMS/HCFA, DOI, State regulations) preferred
  Skills and Abilities
• A thorough knowledge of disease processes and medical and surgical procedures is required.
• Good research, audit skills and prior background in audit-related functions is preferred.
• Must have excellent oral and written communication skills.
• Good analytical, organizational, and interpersonal skills.
• Working knowledge of relevant software (Word, Excel) and ability to learn new applications is necessary.
• Must be able to travel overnight, up to one week, in personal vehicle.
  Licenses and Certifications
• Current, unrestricted Nursing\RN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN licensed to practice in Louisiana 1 year required
• Current, unrestricted Nursing\RN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN license to practice in states other than Louisiana 1 year preferred
• If there is a restriction allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer
• Medical coding background (ICD9 and CPT4) preferred
• Certified Professional Coder (CPC) preferred

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Audit providers to ensure correct medical coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments.
• Resolve CPT or ICD9 reimbursement and medical coding appeals and inquiries for internal and external requests to clarify medical coding issues, clinical editor bundling, medical coding policy, coding-related reimbursement and medical policy issues.
• Identify provider reimbursement related problems, including medical coding and processing issues. Research, audit, and make recommendation for corrective action by providers or BCBSLA.
• Maintain a thorough understanding of medical coding guidelines, provider operations and billing systems, contract benefits, claims procedures, provider contracts and reimbursement agreements.
• Engages in provider relations activities which assist in provider and subscriber problem resolution and maintain a positive Plan image.
• Research and identify excessive medical coding and charge patterns, and over utilization of services to support provider contracting and reimbursement negotiation efforts.
  Additional Accountabilities and Essential Functions
  The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the “My Applications” section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [e-mail] for assistance.

In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.