Payment Integrity Medical Policy Nurse

The Payment Integrity Medical Policy Nurse plays a vital role in shaping and maintaining medical and reimbursement policies that align with national standards and payer guidelines. This position combines clinical expertise and professional coding knowledge to support evidence-based, cost-effective care and ensure sustainable reimbursement practices. The nurse will work closely with cross-functional teams to support medical cost containment efforts and ensure compliance with regulatory and contractual requirements.
Key responsibilities: Developing and maintaining medical coverage and claim payment policies for services under the medical benefitsuch as specialty drugs, medical devices, and surgical procedures. The role requires ensuring alignment with CMS, Medicare Advantage, FDA approvals, and commercial payer standards. Youll apply coding expertise (CPT, HCPCS, ICD-10), particularly in professional/physician settings, to guide policy development and review. Additional duties include analyzing utilization trends and reimbursement data to identify cost-saving opportunities, building business cases to support policy decisions, and presenting recommendations to internal committees. Youll also ensure all policies meet federal and state regulations and stay current with FDA and Medicare updates.

We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to Human Resources Request Form. The EEOC "Know Your Rights" Poster is available here.

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Must-Haves:
1. Active Clinical Allied Certification or License (RN, Pharmacist, LPN, PT, NP, PA)
2. Professional Coding Certification CCS, CPC, RHIA, or RHIT required.
3. 5+ Years of Clinical & Coding Experience Strong background in nursing with hands-on experience in professional/physician coding and billing.
4. Expertise in CMS, Medicare Advantage, and FDA Guidelines Deep understanding of regulatory frameworks and payer reimbursement structures.
5. Policy Development Experience Proven ability to create and maintain medical and reimbursement policies that align with national payer practices and support cost-effective care.

Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.