Clinical Review and Coding Nurse at Capital District Physicians Health Plan Inc in Albany, New York

Job Description:

CDPHP and its family of companies are mission-driven organizations that support the health and well-being of our customers and the communities we are proud to serve. CDPHP was founded in Albany in 1984 as a physician-guided not-for-profit, and currently offers health plans in 29 counties in New York state. The company values integrity, diversity, and innovation, and its corporate culture supports those values wholeheartedly. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The Clinical Review and Coding Nurse is responsible to attain procedure and diagnosis coding accuracy and consistency on referred cases. The RN will perform and coordinate the clinical component of the provider appeal function including communication of the decision on whether to uphold the original payment. The RN will also research new technology or services and recommend updates to medical policies. The RN may also assist in Stop Loss reviews to review member claims and identify potential future high costs.

QUALIFICATIONS:

• Associates degree required. Bachelor's degree preferred.


• RN with a valid New York State license required.


• CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) required, or must be obtain within first year of employment.


• A minimum of two (2) years clinical experience required, preferably within a hospital setting.


• A minimum of two (2) years quality/utilization review experience in an HMO, managed care organization, or similar experience as a hospital inpatient coder or auditor required.


• Demonstrated ability to review health care delivery against established criteria.


• Demonstrated experience working with Microsoft Office, including Outlook, Word and Excel, and other databases.


• Demonstrated knowledge of ICD-10 diagnosis and procedure codes, CPT codes, Revenue codes, HCPCS codes.


• Demonstrated ability to pro-actively identify problems, as well as recommend and/or implement effective solutions.


• Demonstrated ability to work with and maintain confidential information.


• Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.


• Excellent verbal and written communication skills.


• Flexibility to adapt to a changing and fast-paced environment.

As an Equal Opportunity / Affirmative Action Employer, CDPHP does not discriminate in employment practices on the basis of race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

CDPHP and its family of companies include subsidiaries Acuitas Health LLC, Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRX Services, LLC.

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