Payment Integration Clinician I

Job Title: Payment Integrity Clinician I (Remote)Location: Remote — must reside in Oregon (OR), Washington (WA), Idaho (ID), or Utah (UT)Pay Rate: $25–$27 per hourDuration: 6‑month contractPrimary Job PurposeThe Payment Integrity Clinician I is responsible for conducting post‑service clinical reviews of medical claims in a pre‑payment, post‑payment, or audit capacity. This position ensures accurate clinical evaluation, appropriate reimbursement, and proper coding application in accordance with internal medical policies, reimbursement guidelines, and nationally accepted standards. The clinician will evaluate medical records, interpret clinical information, and apply standardized coding and policy criteria to support claim determinations.Key ResponsibilitiesApply clinical expertise to validate compliance with medical and reimbursement policies, guidelines, and accepted standards of care.Review medical records and supporting documentation to ensure alignment with federal regulations, company policies, and industry standards.Conduct claim reviews to ensure accurate payment and appropriate clinical justification.Consult with physician advisors as needed to ensure sound and clinically appropriate determinations.Collaborate with cross-functional departments to resolve member or provider claims adjudication issues.Communicate professionally—verbally and in writing—with internal and external stakeholders while maintaining strict confidentiality.Prioritize and manage assignments to meet performance metrics, organizational goals, and established timelines.Maintain clinical competency by participating in ongoing professional development, medical conferences, workshops, or seminars.Apply working knowledge of clinical coding applications, as appropriate.Complete all continuing education required for maintenance of licensure and certifications.Minimum RequirementsEducation & ExperienceAssociate’s or Bachelor’s degree in Healthcare and3+ years of experience in a clinical setting, health insurance, coding/claims review, case management, or a combination of education and relevant experience; OREquivalent combination of related education and experience.Licensure / Certification (Required)Must hold an unrestricted license or certification in OR, WA, ID, or UT within a health or human services discipline that permits independent assessment within scope of practice.Must meet one of the following:Bachelor’s degree (or higher) in a health or human services–related fieldCurrent unrestricted Registered Nurse (RN) licenseMinimum 3 years of direct clinical care (or full‑time equivalent).Preferred CertificationCertified Professional Coder (CPC) – American Academy of Professional Coders (AAPC)orEquivalent certification through AHIMASkills & CompetenciesKnowledge of medical and surgical procedures and general healthcare practices.Strong ability to interpret medical records, clinical documentation, and patient data.Effective communication skills for both clinical and non‑clinical audiences.High proficiency with Microsoft Word, Excel, PowerPoint, and the ability to learn new systems quickly.Excellent research, analytical, mathematical, and problem‑solving abilities.Ability to work independently in a fast‑paced, rapidly changing environment.Strong attention to detail and ability to manage multiple priorities with minimal supervision.Commitment to high-quality customer service and professionalism.EEO EmployerApex Systems is an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at employeeservices@apexsystems.com or 844-463-6178.