[Hiring] Payment Integrity RN @Blue Cross and Blue Shield of Louisiana

Role Description

This position is responsible for auditing providers to ensure correct medical coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments. Additionally, this position is responsible for complying with all laws and regulations that are associated with duties and responsibilities.

• This role does not manage people.
• This role reports to: MANAGER, PAYMENT INTEGRITY, CLINICAL.
• Necessary Contacts:
  • All levels of BCBSLA personnel
  • Other insurance carriers, agencies, and professional organizations
  • Other Blue Cross Plans
  • Physicians and their office personnel
  • Hospital and allied provider administration and personnel
  • Blue Cross subscribers
  • Medical/surgical suppliers
  • Attorneys
  • Medical specialty organizations (e.g., American College of Obstetric and Gynecology)
  • National medical coding associations (e.g., American Academy of Professional Coders, AHIMA, AMA)
  • Blue Cross Association and CMS (Medicare)

Qualifications

• Bachelor's Degree in Nursing or RN Certification required
• 2 years of experience as an RN required
• Experience in multi-speciality 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
  • Regulatory agency policies (CMS/HCFA, DOI, State regulations)
• A thorough knowledge of disease processes and medical and surgical procedures is required
• Good research, audit skills, and prior background in audit-related functions is preferred
• Excellent oral and written communication skills
• Good analytical, organizational, and interpersonal skills
• Working knowledge of relevant software (Word, Excel) and ability to learn new applications is necessary
• Must be able to travel overnight, up to one week, in personal vehicle
• Current, unrestricted Nursing/RN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN licensed to practice in Louisiana 1 year required
• Current, unrestricted Nursing/RN - Registered Nurse - State Licensure And/Or current, unrestricted Compact State Licensure RN license to practice in states other than Louisiana 1 year preferred
• Medical coding background (ICD9 and CPT4) preferred
• Certified Professional Coder (CPC) preferred

Requirements

• Audit providers to ensure correct medical coding and billing practices, enforce reimbursement and member agreement compliance, and recover incorrect payments
• Resolve CPT or ICD9 reimbursement and medical coding appeals and inquiries for internal and external requests to clarify medical coding issues, clinical editor bundling, medical coding policy, coding-related reimbursement, and medical policy issues
• Identify provider reimbursement related problems, including medical coding and processing issues. Research, audit, and make recommendations for 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 which assist in provider and subscriber problem resolution and maintain a positive Plan image
• Research and identify excessive medical coding and charge patterns, and over-utilization of services to support provider contracting and reimbursement negotiation efforts

Benefits

• Resources to live well and be healthy
• Opportunities for continued learning and skill development
• Support for professional growth
• Engagement with local communities