Nurse Claim Auditor

at USA Medical Staff (view profile)
Location Boston, Massachusetts
Date Posted April 28, 2021
Category Nurse - Other
Job Type Full Time


Salary range - $ 110,000 - $ 115,000


Associate's Degree in Nursing

2 plus years Clinical/ Auditing/ Utilization Management experience

2 plus years of health plan experience


Coding Certificate is a plus


Job Description
Why This Role is Important to Us
This position is for a Nurse Claims Auditor for complex medical claims. This role will be instrumental to the Payment Integrity/Claims team. This role will be responsible for reviewing a wide variety of medical claims to ensure all payment integrity needs are met to ensure payment accuracy. The claims will be Medicare, Medicaid and Mass Health claims. They will act as part of a larger team to share information and collaborate on ongoing efforts to ensure overall payment integrity. This position will report to the Director, Payment Integrity.
What We're Looking For
- Diploma in Nursing, Associate’s Degree in Nursing, Bachelor's Degree preferred - 5+ years clinical/auditing and/or utilization management experience - 2+ years’ experience working with a health plan, performing audits to ensure payment integrity is maintained based on appropriate rules, regulations and corresponding contract language. - Registered Nurse licensed in the Commonwealth of Massachusetts in good standing. - Will be required to pass CCA’s credentialing process. - Experience with Dual Eligibility, Medicare, Medicaid and Mass Health. - Knowledge of CPT, ICD10, HCPCS or other coding structures are required. - Knowledge of UB-04s, CMS 1500 forms, and itemized statements - Demonstrated ability to establish and manage performance and outcome metrics. - Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners. - Familiarity with InterQual criteria applied to procedures - Understanding of individualized complex care plans - Understands and recognizes medical and insurance terminology - Strong strategic thinker and tactical performer - Strong project management skills with the demonstrated ability to handle multiple projects. - Ability to establish and maintain positive and effective work relationships with internal staff, external vendors, and state and federal agencies - Proven skills and judgment necessary for independent decision-making. - Excellent organizational, time-management and problem-solving skills - Ability to influence decision making - Microsoft office products and claims software - Excellent verbal and written communications skills are essential - Candidate must be able to prioritize work and use independent judgment
What You'll Be Doing
- Conducts claim audits looking for overpayments, including potentially preventable readmissions, unnecessary procedures, excessive units billing and potential fraud waste and abuse. - Perform trend analysis of claims for Payment Integrity and quality assurance. - Work with various other areas within CCA, such as Contracting, FWA and Clinical teams to ensures clarity and accuracy in all phases of the payment integrity claims process. - Responsible for reviewing medical records and claims as needed to ensure payment accuracy, adherence to payment policies, regulations and provider contract obligations. - Ensures optimal system coding that adhere to all billing compliance standards. - Ensures timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements. May require collaboration with internal business partners. - Manages the process for escalated reviews in accordance with Standard Operating Procedures. - Ensures that departmental and organizational policies and procedures as well as regulatory and contractual - requirements and other regulatory reporting needs are met.

Company Culture & Perks

Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.

Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.

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