Payment Integrity Clinician - Remote

Overview

The Payment Integrity Clinician is responsible for identifying issues related to provider claims data, ensuring appropriate payment and satisfaction for providers and members through effective review processes.

In Short

• Identify issues related to professional and facility provider claims data.
• Implement Payment Integrity strategies for claims review.
• Analyze medical documentation, itemized bills, and claims data.
• Educate network providers on billing practices.
• Monitor and analyze healthcare service delivery.
• Act as a resource for colleagues on complex issues.
• Drive project completion related to Payment Integrity.
• Ensure compliance with state and federal laws.
• Maintain positive relationships with internal and external customers.
• Practice ethical principles in all reviews.

Requirements

• Associate's Degree in Nursing required; Bachelor's preferred.
• 3-5 years of experience in a clinical setting required.
• Current RN licensure in PA or multi-state licensure.
• Certified Medical Coder preferred.
• Ability to solve complex issues with minimal direction.
• Excellent communication and problem-solving skills.
• Experience with healthcare claims and data analysis.
• Familiarity with coding criteria and medical policies.
• Understanding of regulatory compliance in healthcare.
• Ability to educate others on Payment Integrity processes.

Benefits

• Competitive salary range based on experience.
• Comprehensive health benefits.
• Opportunities for professional development.
• Flexible working arrangements.
• Supportive work environment.
• Access to company resources and training.
• Potential for career advancement.
• Work-life balance initiatives.
• Employee wellness programs.
• Diversity and inclusion initiatives.