State Licensed Payment Integrity Nurse

Job Summary

Analyzing hospital claims, the full-time State Licensed Payment Integrity Nurse will perform detailed audits, identify billing discrepancies, and negotiate adjustments on behalf of ASO clients in a remote setting.

Key Responsibilities

• Perform detailed audits of hospital claims and analyze DRG assignments to validate billing accuracy and identify irregularities
• Serve as a subject matter expert and advocate for clients in disputes with claims administrators, preparing documentation to support claim adjustments
• Analyze large claims data sets to identify trends and maintain tracking logs of recovered savings

Required Qualifications

• Hospital/Surgical/ICU Nursing background (RN) with clinical coding experience for DRG validation
• 5+ years of experience in hospital claims analysis, auditing, or payment integrity, particularly with self-funded/ASO plans
• Strong knowledge of DRG methodology, UB-04 billing, and coding standards (ICD-10-CM/PCS, CPT/HCPCS)
• Experience with stop loss insurance and high-cost claims analysis
• Proficiency in claims data analysis tools, particularly Excel; familiarity with SQL or Access is a plus