Clinical Coding Nurse Analyst (Program and Payment Integrity)
Clinical Coding Nurse Analyst (Program and Payment Integrity) Requisition #: 450983 Location: Johns Hopkins Health Care, Hanover, MD 21076 Category: Coding Work Shift: Day Shift Work Week: Full Time Weekend Work Required: No Date Posted: Dec. 10, 2021Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth. Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.This can be a virtual work position depending on the State of residence. Must reside in one of the following to be considered: MD, VA, FL, PA, DE or District of Columbia.Position Summary: Assists in the development, implementation, and ongoing monitoring of associated with payment integrity audits with codes related to clinical functions at JHHC. Works in collaboration with other departments to ensure accurate coding within Care Management medical policies, and all published guidelines. Responsibilities also include the administrative support of various committees in preparing documents with correct coding and preparation. Acts as a consultant to other departments related to coding. Provides consultation and expertise to the Medical Payment Policy team as needed, including collection of all appropriate nationally recognized agency studies, standards and published articles in order to support any/all recommended policies. Using the clinical review nursing process of subjective and objective review and analysis, make recommendations for policy development and revision, elevate questions of concern, risk or recommendation to appropriate Department. Conducts DRG, DME, Hospital bill audits and high dollar claims review on selected claims and validate claims audits conducted by a PI vendor. The Clinical Coding Nurse Analyst will adapt to client needs and provide a wide range of coding reviews as projects vary from initial development and implementation of a formal clinical audit documentation and ongoing maintenance of existing programs. May require travel to provider locations throughout the state.Requirements: Education: Requires completion of an approved course of study in nursing with a baccalaureate degree required and coding certification preferred or able to qualify for taking the coding certification exam within six months. Active nursing license, preferred in the State of Maryland. Knowledge: Must exhibit knowledge of CPT, HCPCS, ICD9, and analysis of processes of clinical care as related to coding standards and principles. Knowledge of managed care organizations and policy research and development required. Knowledge of medical policy principles and practice required. Knowledge of ICD10 strongly preferred. Knowledge of various criteria sets Knowledge and experience in Medical Policy research and development Skills: Excellent computer skills working with a variety of databases, excel, word, and claims systems. Requires the ability to work both independently and as a member of the JHHC team. Must possess planning and organizational skills. Must demonstrate ability to accept and institute change. Must have strong analytical skills and statistical aptitude. Requires excellent verbal, written and listening communication skills and the ability to be detail-oriented and well organized. Requires excellent interpersonal skills and the ability to maintain a credible and professional image with staff, members, physicians and business-related individuals Required Licensure, Certification, Etc.: Coding certification preferred or able to qualify for taking the coding certification exam within six months. Active nursing license, preferred in the State of Maryland. Work Experience: Minimum of 5 years of clinical audit, including Hospital Audits, Readmission and DRG audits, with at least 3 years of managed care experience is required. A minimum of 1-2 years coding experience as it relates to Medical Review. Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.