RN CPC (coding license REQUIRED, 5+yrs of OR exp)
5128 Apache Plume Rd. Suite 400 Benbrook, TX 76109 US
Job Description
Direct Hire
Salary range $100K-$115K DOE
JOB SUMMARY:
The Policy and Payment Integrity Manager oversees the PPI team and assists with implementation of policies to perform reviews including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation. In this position, you will be managing members of the PPI team including developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress.
The manager in this role provides trend analysis of internal auditing of claims for claim accuracy related to pre and post payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review to determine the claim accuracy; assist with development of internal quality assurance measures based on client policy and industry guidelines; perform quality assurance reviews (as needed); assist in researching and implementing best practices related to payment policy, and/or policy initiatives; researching various healthcare policies; interpreting client, state, and CMS payment policies; assist in writing internal quality assurance policies; work with department managers in implementing payment policies and processes to meet quality assurance guidelines.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- Assists with development and modification of standard operating procedures for PPI team.
- Exercises good judgment to resolve complex claim and appeal issues and makes sound decisions in the absence of detailed instructions or in an emergency situation
- Participates in discussion with internal and external stakeholders in regards to reviews including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation.
- Research, interpret and apply CMS, Federal, State and client policies to claims review
- Verbally communicate interpretation of CMS, Federal, State and client policies to providers
- Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule
- Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
- Works with operational leaders within the business to provide recommendations on opportunities for process improvements.
- Strong knowledge of itemized bill review, ASC and outpatient claim review
- Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format
- Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits
- Strong understanding of healthcare revenue cycle and claims reimbursement
- Proficient in Microsoft Office including Pivot Tables and Database Management
- Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule
- Proven track record of delivering concrete results in strategic projects/programs
- Strong analytical and modeling ability and distilling data into actionable results
- Superb attention to detail and ability to deliver results in a fast paced and dynamic environment
EDUCATION/EXPERIENCE:
- Must maintain a current RN licensure in the state of employment
- Must maintain a current coding license (CPC, CCS, RHIT, etc)
- 3+ years of management experience
- Minimum of 5 years’ experience in Operating Room, either as a circulating RN or scrub RN, as well as 2 years’ clinical experience in an acute care facility
- Previous experience in the following areas preferred:
- Medical bill coding and auditing
- DRG and Clinical Validation
- Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry,
- Bachelor’s degree in healthcare or related field
- 5+ years of relevant experience or equivalent combination of education and work experience
- 3+ years hospital bill audit
Medical/Dental
401K
PTO
Employee stock purchase plan
Quick apply on line or text David at 972-346-0506
#CSM3
Meet Your Recruiter
David McClanahan
Operations Manager
David has been in healthcare recruiting for 2 years, placing candidates in all areas of a Hospital/Clinic. He enjoys building strong relationships with his candidates/clients, while helping fill important assignments in his community. David is originally from Galveston, TX but relocated in 2005 to the DFW area to play Baseball in college. David graduated from Northwood University in 2009 with a BBA. He enjoys watching all of Houston sports team, playing Golf and spending time on the weekend with his family.