Philadelphia, PA

Overview

We are seeking a detail-oriented and experienced Payment Integrity Nurse to join our Claim Payment Policy team. This critical role leverages clinical and coding expertise to support the development and implementation of reimbursement and medical payment policies. The ideal candidate is a licensed nurse with strong coding knowledge who thrives on driving cost-effective utilization, maintaining policy compliance, and ensuring payment accuracy across the healthcare landscape.

Key Responsibilities

• Policy Development: Create and maintain medical and reimbursement policies that align with national standards, internal benefit structures, provider contracting, and state/federal mandates.
• Clinical & Coding Expertise: Apply clinical judgment and medical coding knowledge (CPT, HCPCS, ICD-10) to evaluate claim trends, develop comprehensive code sets, and support appropriate reimbursement practices.
• Documentation & Presentation: Prepare and present Claim Payment Policy Bulletins to internal workgroups and leadership committees. Incorporate feedback and update documentation accordingly.
• Utilization Analysis: Assess utilization trends, identify cost-effective opportunities, and contribute to medical cost savings initiatives.
• Cross-functional Collaboration: Serve as a subject matter expert (SME) in clinical and coding areas, supporting various teams and departments on projects, audits, and claims analyses.
• Project Support: Contribute to business case development for clinical and payment initiatives, helping guide organizational decision-making.
• Stakeholder Engagement: Work collaboratively across departments and with external partners including vendors, consultants, and regulatory organizations.
  
  

Qualifications

• Education: Bachelor’s degree in Nursing (BSN) or equivalent work experience.
• Licensure: Active RN license required (PA RN license strongly preferred).
• Certification: Valid medical coding certification (CCS, CPC, RHIA, or RHIT).
• Experience:
• Minimum 5 years of clinical experience with a strong foundation in medical coding.
• Proven knowledge of CPT, HCPCS, and ICD-10 coding systems.
• Familiarity with healthcare reimbursement principles, insurance policies, and Medicare regulations.
• Skills:
• Excellent analytical, organizational, and communication skills.
• Comfortable presenting complex data to diverse audiences.
• Ability to prioritize tasks, work independently, and meet critical deadlines.
• Strong stakeholder management and team leadership abilities.