Payment Integrity RN

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.