Job Description

Medical Associates is looking for a Clinical Documentation Improvement & Payment Integrity Registered Nurse to join our Quality Improvement team!

Schedule: Primary schedule will be Monday through Friday 8:00am to 5:00pm, 40 hours/week. After training, there is opportunity for work from home if desired!

Location: Training is in-person at Medical Associates Health Plans, 1605 Associates Drive, Dubuque, IA 52002

Benefits Package Includes:

• Single or Family Health Insurance with discounted premium rates for wellness program participation.
• 401k with immediate matching (50% on the dollar up to 7% of pay + additional annual Profit Sharing)
• Flexible Paid Time Off Program (24 days off/year)
• Medical and Dependent Care Flex Spending Accounts
• Life insurance, Long Term Disability Coverage, Short Term Disability Coverage, Dental Insurance, etc.

What You Will Be Doing:

• Perform clinical review of medical records, claims, encounter data, and supporting documentation to ensure accurate diagnosis capture, coding specificity, appropriate reimbursement, regulatory compliance, and payment accuracy
• Collaborate with providers, coding professionals, quality teams, utilization management, care management, and external vendors to improve documentation quality, identify coding opportunities, prevent payment errors, and support organizational quality and financial goals.

Essential Functions & Responsibilities:

• Perform clinical review and validation of medical records, claims, encounter data, and supporting documentation to ensure complete and accurate capture of diagnoses and conditions impacting risk adjustment, quality reporting, and reimbursement.
• Conduct prospective and retrospective chart reviews.
• Identify opportunities for improved diagnosis specificity and documentation.
• Validate diagnosis coding and clinical support for reported conditions.
• Monitor and track risk adjustment opportunities and outcomes.
• Assist in closing documentation and coding gaps.
• Support payment integrity activities by reviewing claims and clinical documentation for accuracy, appropriateness, medical necessity, and compliance with applicable guidelines and policies.
• Participate in pre-payment and post-payment audit activities.
• Identify potential overpayments, underpayments, duplicate payments, and billing discrepancies.
• Support investigations related to coding, billing, and documentation concerns.
• Collaborate with internal departments and external vendors on payment integrity initiatives.
• Assist with reviews related to fraud, waste, and abuse referrals when clinically indicated.
• Provide education and consultation to providers, coders, clinical staff, and operational teams regarding documentation, coding, regulatory requirements, and payment integrity best practices.
• Develop educational materials and provider feedback reports.
• Deliver individual and group education sessions.
• Promote accurate and complete clinical documentation practices.
• Communicate coding and documentation trends and opportunities for improvement.
• Analyze and monitor data to identify trends, opportunities, and program outcomes.
• Maintain tracking databases and reporting tools.
• Monitor coding gap closure rates, audit findings, and payment integrity outcomes.
• Prepare reports and recommendations for leadership.
• Collaborate with Quality Improvement, Utilization Management, Care Management, Credentialing, Provider Relations, and Finance teams to support organizational goals related to quality, regulatory compliance, risk adjustment performance, and payment integrity.
• Perform other duties, special projects, audits, and analyses as assigned.

Knowledge, Skills and Abilities:

Experience - Three years to five years of similar or related experience.

Education - Valid RN nursing license is required.