Conduct detailed clinical and coding evaluations to ensure claim payments are accurate.
Review medical records and appeal submissions to assess coding accuracy.
Serve as a subject matter expert for claim payment accuracy including pre-payment claim editing and auditing.
Coordinate with vendors and internal teams to design and implement payment integrity solutions.
Collect, analyze, synthesize, and interpret multiple sources of data.
Lead technology/tool updates, testing, and troubleshooting with IT teams and vendors.
Respond to payment integrity inquiries from providers, internal teams, and vendors.
Manage multiple projects or audits with minimal supervision.
Collaborate with appropriate departments regarding payment integrity issues identified during auditing processes.
Develop and facilitate presentations by analyzing and interpreting data to communicate business issues and findings.

Requirements

Bachelor's Degree or (4) years of work experience. (Required)
(4) years of analytical experience in a technical, healthcare, or business-related discipline, including (2) years of experience leading small to medium size projects. (Required)
Comprehensive knowledge of CPT, ICD10, HCPCS or other coding structures. (Required)
Current State Licensure as a Registered (RN) or Licensed Practical (LPN) Nurse where licensing is required by state law. (Strongly preferred)
(4) years of experience with healthcare claims processing systems or provider billing and revenue cycle management systems. (Preferred)
Certified Professional Coder designation. (Preferred)
Certified Internal Auditor. (Preferred)
Previous Payor experience. (Preferred)
Certified as a Six Sigma or Lean leader. (Preferred)
Experience with various querying tools, including MS SQL Server, SAS. (Preferred)
Demonstrated advanced skills in Microsoft Office Suite: Outlook, Word, Excel, PowerPoint. (Preferred)

Benefits

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Applicant Tracking System Keywords

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Hard Skills & Tools

coding evaluationscoding accuracypayment integrity solutionsdata analysisproject managementCPTICD10HCPCShealthcare claims processingrevenue cycle management

Soft Skills

leadershipcommunicationcollaborationanalytical skillstroubleshootingpresentation skillsorganizational skillsproblem-solvingindependencevendor coordination

Certifications

Registered Nurse (RN)Licensed Practical Nurse (LPN)Certified Professional CoderCertified Internal AuditorSix Sigma certificationLean certification