Clinical Payer Integrity Nurse

At UK St. Claire, our staff is our greatest asset in the mission to create a healthier and more prosperous population. We strive to foster the talent and potential of our employees and prioritize safe working conditions and equal compensation rates to ensure that continual growth is possible. UKSC is a nurturing workplace for all healthcare professionals. We invite you to explore our current job openings and see if our opportunities could be the right fit for you.

Job Description:

Job Summary

Responsible for ensuring accurate reimbursement by resolving denied claims through effective appeals processes. Reviews and analyzes denials to identify root causes and opportunities for successful resolution. Collaborates with clinical and billing teams to gather documentation and support appeals. Develops strategies to retain appropriate reimbursement and monitors outcomes to improve future processes. Coordinates with providers, coding, billing, and payer representatives to enhance claims and reimbursement effectiveness.

Essential Functions

• Conducts clinical reviews of claims and documentation to ensure compliance with payer policies, medical necessity, and clinical standards of care.

• Analyzes denial trends related to clinical care, identifies root causes, and develops strategies for resolution and prevention.

• Researches patient records and clinical documentation to gather information supporting appeals.

• Reports and records denials using designated systems and ensures that the clinical documentation supports the services billed.

• Reviews and interprets third-party contract language and payment models.

• Analyzes hospital claims for accurate charges and documentation.

• Completes and processes appeals within required timeframes and deadlines while referencing guidelines and standards of care.

• Assists internal and external customers with denials, appeals, and payment inquiries.

• Communicates daily with clinical departments, revenue cycle teams, and payers to facilitate resolution of clinical billing disputes..

• Performs other duties as assigned.

Education Requirement

Bachelor’s degree in nursing, healthcare administration, or a related field

Master’s degree in nursing, healthcare administration, or a related field is preferred

Experience Requirement

2-3 years of experience in clinical review, payer integrity, utilization management, or a relevant area

An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Certifications & Licensures

Maintains active RN licensure

Working Conditions

A. Lifting, pushing, and/or pulling objects up to 50lbs: 2. Occasional (< 10% of the time)

B. Lifting, pushing, and/or pulling objects over 50lbs: 1. Never

C. Standing or walking with objects up to 10lbs: 3. Intermittent (10% - 50% of the time)

D. Standing or walking with objects up to 25lbs: 2. Occasional (< 10% of the time)

E. Sitting at computer workstation for extended periods: 4. Regular (> 50% of the time)

F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials: 1. Never

G. Repetitive motion: 4. Regular (> 50% of the time)

H. Working at heights above 4 feet: 1. Never

I. Working in confined spaces: 1. Never

J. Risk of injuries from use of equipment on the job: 1. Never

K. Job-related travel: 2. Occasional (< 10% of the time)

L. Loud noises: 1. Never

M. Temperature extremes: 1. Never

N. Hazardous chemicals and fumes including waste: 1. Never

O. Radiation: 1. Never

P. Burns: 1. Never

Q. Cuts/Punctures: 1. Never

R. Bloodborne/airborne pathogens: 1. Never

S. Recombinant DNA or viral vectors: 1. Never

T. Combative/violent people: 1. Never

U. Animal handling (including carcasses): 1. Never

V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

Physical Demands

This position requires intermittent sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds; occasional standing or walking with objects up to 25 pounds; and occasional lifting, pushing, and/or pulling objects weighing up to 50 pounds.

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