Payment Integrity Nurse I

This is a fully remote position, open to applicants in Idaho, +3 more states.

📋 Description

• Utilizes nursing expertise to ensure adherence to medical and reimbursement policies, guidelines, and accepted standards of care.

• Guarantees that medical records and documentation meet federal regulations, company policies, and industry standards.

• Assists members and providers by conducting reviews of claims and related medical records (when necessary) to ensure accurate claims payment.

• Consults with physician advisors to confirm clinically appropriate determinations.

• Works collaboratively with other departments to address member or provider claims adjudication concerns.

• Communicates in writing or by phone with internal and external customers in a professional and diplomatic manner, ensuring the confidentiality of sensitive documents and issues.

• Plans, organizes, and prioritizes tasks to meet performance standards, corporate objectives, and established timelines.

• Takes responsibility for maintaining clinical competency, such as attending relevant medical conferences, workshops, and seminars related to current medical practices, procedures, and the healthcare industry at least once a year.

• Demonstrates a working knowledge of clinical coding applications as applicable.

• Engages in courses and continuing education to uphold licensure and relevant certifications.

⛳️ Requirements

• Associate's or Bachelor's Degree in Healthcare.

• At least 3 years of experience in a clinical setting, health insurance, coding/claims review, case management, or a comparable combination of education and experience.

• Unrestricted licensure or certification in OR, WA, ID, or UT in a health or human services discipline that permits independent assessment within the scope of practice (medical or behavioral health).

• A minimum of 3 years (or full-time equivalent) of direct clinical care experience.

• Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or a Master's degree in Behavioral Health preferred for behavioral health), OR a current unrestricted Registered Nurse (RN) license.

• Preferred: Certified Professional Coder (CPC) certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).

🏝️ Benefits

• Medical, dental, and vision coverage for employees and their eligible family members, including mental health benefits.

• Annual employer contribution to a health savings account.

• Generous paid time off that varies by role and tenure, in addition to 10 company-paid holidays.

• Market-leading retirement plan that includes a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).

• Up to 12 weeks of paid parental leave (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).

• Award-winning wellness programs that reward participation.

• Employee Assistance Fund available for those in need.

• Commute and parking benefits.