Payment Integrity RN

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Conduct audits of providers to verify accurate medical coding and billing practices.

• Ensure compliance with reimbursement and member agreements.

• Recover payments that have been made incorrectly.

• Address appeals and inquiries related to CPT or ICD9 reimbursement and medical coding.

• Provide clarification on coding issues, clinical editor bundling, coding policy, reimbursement associated with coding, and medical policy matters.

• Detect issues related to provider reimbursement, including coding and processing challenges.

• Investigate, audit, and suggest corrective actions to be taken by providers or BCBSLA.

• Maintain a comprehensive understanding of coding guidelines, provider operations, billing systems, contract benefits, claims procedures, provider contracts, and reimbursement agreements.

• Participate in provider relations activities to resolve issues faced by providers and subscribers while upholding a positive image of the Plan.

• Analyze excessive coding and charge patterns, as well as overutilization of services, to aid in contracting and reimbursement negotiations.

• Carry out additional job-related responsibilities as required.

⛳️ Requirements

• A Bachelor's Degree in Nursing or RN Certification is mandatory.

• A minimum of 2 years of experience as an RN is required.

• Residency in or willingness to relocate to Louisiana is preferred.

• Candidates must be authorized to work for Louisiana Blue in the United States without the need for employer-sponsored immigration support.

• Current, unrestricted RN state licensure or compact-state RN licensure is required; RN must be licensed to practice in Louisiana.

• Current, unrestricted RN license to practice in states other than Louisiana is preferred.

• Willingness to travel overnight for up to one week in a personal vehicle.

• In-depth knowledge of disease processes and medical and surgical procedures is essential.

• Exceptional oral and written communication skills are necessary.

• Strong analytical, organizational, and interpersonal skills are required.

• Proficiency in Word and Excel, with the capacity to learn new applications.

• Experience in a multispecialty setting is preferred.

• Familiarity with provider billing practices, AMA coding guidelines, Correct Coding Initiative edits, physician specialty guidelines, BCBSLA reimbursement programs, provider agreements, claims adjudication processes, and regulatory agency policies is preferred.

• Strong research and audit skills, along with prior audit-related experience, are preferred.

• A background in medical coding (ICD9 and CPT4) is preferred.

• Certification as a Professional Coder (CPC) is preferred.

• Any licensure restrictions must not hinder the health professional’s ability to meet reviewer responsibilities.

🏝️ Benefits

• Access to resources that promote a healthy and fulfilling lifestyle.

• Opportunities for continuous learning and skill enhancement.

• Professional development and growth opportunities.

• Chances to contribute to local communities.

• Reasonable accommodations available for individuals with disabilities.

• A smoke- and tobacco-free workplace environment.

• Background checks and pre-employment drug screenings are conducted.