Payment Integrity Nurse Coder RN II

L.A. Care Health Plan - Los Angeles, CA

Job Title: Payment Integrity Nurse Coder RN II

Position: Nurse Coder

Job Type:

Pay: $88,854.00 - $132,838.00 - $163,492.00

Shift:

Work Type:

Location

Address:

City: Los Angeles

State: CA

ZIP Code:

Job Responsibilities

Perform quality audits to include validation of accuracy and completeness of ICD, Rev Code, CPT, HCPCs, APR, DRG, POA, and all relevant coding elements, including inpatient, outpatient, and professional claims.
Serve cross-functionally with Utilization Management, Medical Directors, and internal teams to assist in identification of overpayments and other projects.
Learn and become knowledgeable in all Payment Integrity functions, including both Retrospective Data Mining and Pre-Payment Cost Avoidance.
Identify trends and patterns with overall program and individual provider coding practices.
Support the creation and execution of strategies that determine impact of opportunity and recover overpayments, as well as prospective internal controls preventing future overpayments.
Work with internal and external groups to define and develop cost avoidance measures.
Identify and define Payment Integrity issues, review and analyze evidence, utilize data for verifying and identifying systemic errors.
Work collaboratively as an active team member during engagements and provide feedback to the team lead on issues identified during research or claims review.
Perform other duties as assigned.

Required Skills

Core Skills

Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.
Investigation and/or auditing experience.
Knowledge of healthcare reimbursement concepts and health insurance business.
Working knowledge of claims coding and medical terminology.
Solid understanding of standard claims processing systems and claims data analysis.
Strong project leadership and management skills.
Excellent interpersonal, verbal, and written communication skills.
Analytical and problem-solving skills.
Detail-oriented and able to thrive in a fast-paced work environment.
Familiarity with coordinating benefits between health plan payers.
Advanced knowledge of Microsoft Office suite.

Preferred Skills

Not specified

Requirements

Experience: At least 5-7 years clinical experience and a minimum of 2 years in utilization management or clinical coding.

Education: Associate's Degree in Nursing

License & Certification:

Registered Nurse (RN) - Active, current and unrestricted California License
Certified Professional Coder (CPC) designation by the American Academy of Professional Coders
Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA)

Schedule:

COVID-19 Requirements: Not Specified

Benefits

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Supplemental Pay

Not specified

Special Notes

Responsible for completing an approved certified coding course within six months of date of hire.
Must obtain Certified Professional Coder (CPC) designation by the American Academy of Professional Coders.
Current Certified Coding Specialist (CCS) designation by AHIMA required within one year of date of hire.

Facility Details

Name: L.A. Care Health Plan

Description: An independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. The nation’s largest publicly operated health plan, serving over 2 million members.

Specialties:

Health Coverage
Healthcare

Mission: To provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.