Payment Integrity RN

Blue Cross and Blue Shield of Louisiana•Remote-LA, LA

About The Position

This position audits providers to ensure correct medical coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments. It also resolves coding and reimbursement appeals and inquiries, identifies provider reimbursement problems, researches coding and charge patterns, and supports corrective action and provider contracting efforts. The role must comply with laws and regulations associated with its duties. The position does not manage people and reports to the Manager, Payment Integrity, Clinical. The employee works with BCBSLA personnel, other insurers and organizations, providers and their staff, subscribers, suppliers, attorneys, professional coding and medical organizations, the Blue Cross Association, and CMS. The job is performed in a normal, clean office environment with normal noise levels. Work is predominantly performed while standing or sitting. Overnight travel of up to one week in a personal vehicle is required. Residency in or relocation to Louisiana is preferred. Applicants must be authorized to work in the United States without employer-sponsored immigration support.

Requirements

Bachelor's degree in Nursing or RN certification required.
At least 2 years of experience as an RN required.
Current, unrestricted RN state licensure or compact state licensure to practice in Louisiana, held for at least 1 year, required.
Thorough knowledge of disease processes and medical and surgical procedures required.
Excellent oral and written communication skills required.
Good analytical, organizational, and interpersonal skills required.
Working knowledge of relevant software, including Word and Excel, and ability to learn new applications required.
Ability to travel overnight for up to one week in a personal vehicle required.
If a restriction is allowed by a relevant jurisdiction, it must be of a type that does not affect the health professional’s ability to fulfill reviewer responsibilities, as determined by the medical director or clinical director.
Must be authorized to work in the United States without employer-sponsored immigration support.

Nice To Haves

Residency in or relocation to Louisiana preferred.
Experience in a multispecialty 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, and state regulations) preferred.
Research and audit skills and prior experience in audit-related functions preferred.
Current, unrestricted RN licensure or compact state licensure to practice in states other than Louisiana, held for at least 1 year, preferred.
Medical coding background (ICD9 and CPT4) preferred.
Certified Professional Coder (CPC) preferred.

Responsibilities

Audit providers to ensure correct medical coding and billing, enforce reimbursement and member agreement compliance, and recover incorrect payments.
Resolve CPT or ICD9 reimbursement and medical coding appeals and inquiries, including issues involving clinical editor bundling, medical coding policy, coding-related reimbursement, and medical policy.
Identify provider reimbursement problems, including medical coding and claims processing issues; research and audit them and recommend 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.
Engage in provider relations activities to help resolve provider and subscriber problems and maintain a positive Plan image.
Research and identify excessive medical coding and charge patterns and overutilization of services to support provider contracting and reimbursement negotiations.
Perform other job-related duties as assigned within the scope of responsibilities.