Job Description

The Payment Integrity Nurse Coder RN III is responsible for investigating, reviewing, and providing clinical and/or coding expertise/judgement in the application of medical and reimbursement policies within the claim adjudication process through medical record review for Payment Integrity and Utilization Management projects.

The position serves as a subject matter expert (SME), performing medical records reviews to include quality audits as well as validation of accuracy and completeness of all coding elements. The position is also responsible for guidance related to Payment Integrity initiatives to include concept and cost avoidance development.

This position trains and mentors Payment Integrity Nurse Coder, RN staff. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Qualifications

Education Required:

• Associate's Degree in Nursing

Education Preferred:

• Bachelor's Degree in Nursing

Experience Required:

• At least 8 years of clinical RN experience. 
• At least 3 years of experience in utilization management or clinical coding. 
• Investigation and/or auditing experience.

Skills Required:

• Knowledge in CPT, HCPCS, ICD-9, ICD-10, Medicare, and Medicaid rules and regulations. 
• Knowledge of healthcare reimbursement concepts, health insurance business, industry terminology, and regulatory guidelines. 
• Working knowledge of claims coding and medical terminology. 
• Solid understanding of standard claims processing systems and claims data analysis.

Licenses/Certifications Required:

• Registered Nurse (RN) - Active, current and unrestricted California LicenseCertified Professional Coder (CPC) designation by the American Academy of Professional Codersand/or Certified Coding Specialist (CCS) designation by the American Health Information Management Association (AHIMA).

About the Hospital

As the nation's largest publicly-operated health plan, we have a great responsibility to the communities we serve, and our employees play an essential role in ensuring we meet those needs.

Why Join Us?
Opportunity. Amazing co-workers. A supportive management team. Great compensation and benefits. Camaraderie and a true sense of mission. If you want a career that truly contributes to the good of all, join us as we work towards a healthier L.A.