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Clinical Nurse Auditor

Job Summary:

This position performs audits of medical records on behalf of hospital clients for denial review, disallowed charges, and utilization reviews. This position requires critical thinking and judgment and must demonstrate the ability to appropriately use standard criteria such as InterQual and MCG in addition to criteria established by state Medicaid programs or hospital contract or policy. Audit and analysis must be accurate and consistently ensure a high level of quality, knowledge of state and federal laws, rules, regulations and guidelines necessary to ensure compliance and protection of information.

Essential Duties and Responsibilities

  • Defends audits of outpatient medical records to identify and/or defend charges, including: Patient Inquiry Audit, Charge Hold Audits, Biller Requested Audits
  • Completes analysis of records for outpatient reviews such as: Denied line items, Experimental denials.
  • Reviews medical records against established criteria (MCG, InterQual, Medicare and Medicaid) to determine if patient condition and/or care meets criteria
  • Determine, request, and obtain appropriate supporting documentation from hospital, physicians, current medical literature and/or patient
  • Composes appeal letters addressing and appealing both contract issues and medically related issues
  • Become familiar with assigned facilities CDM and departmental charge protocol
  • Organizes and prioritizes multiple cases concurrently to ensure departmental workflow and timely case resolution
  • Identifies trends for clients for denial prevention opportunities
  • Enter findings and other supporting documentation into Savista’s computer based system.
  • Proficiently utilize multiple computer based systems to complete and document work
  • Function in a professional, efficient and positive manner
  • Must be customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
  • Maintain confidentiality of patient information and abide by all HIPAA related guidelines

Minimum Requirements & Competencies:

  • LPN
  • 3 to 5 years of hospital/clinical experience
  • Knowledge of MCG and/or InterQual criteria
  • Experience in medical records review, claims processing or utilization/case management in a hospital, clinical practice or managed care organization
  • Fundamental knowledge of Medicare/Medicaid Guidelines
  • Proficiency in navigating the internet and multi-tasking with multiple electronic documentation systems simultaneously (toggling)
  • Demonstrated ability to navigate Internet Explorer and Microsoft Office, including the ability to input and sort data in Microsoft Excel and use company email and calendar tools.
  • Demonstrated success working both individually and in a team environment.
  • Demonstrated experience communicating effectively with payers, understanding complex information and accurately documenting the encounter.
  • Ability to work effectively with cross-functional teams to achieve goals.
  • Demonstrated ability to meet performance objectives.

Preferred Requirements & Competencies:

  • Experience with Epic, Meditech, Cerner, Invision, Paragon, Soarian, Collections Management or STAR.
  • Experience working with or for a hospital/hospital system with more than 250 beds.
  • Experience with both hospital (facility) and physician (pro-fee) A/R.

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