About The Position
This auditing role will be responsible for performing retrospective clinical chart reviews on Readmission and Place of Service Claims by utilizing nationally accepted guidelines, clinical review judgment and review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, applying critical thinking and decision-making skills, and accurately documenting a rationale with the findings and supporting references. The ideal candidate for this role would be a Registered Nurse with experience in utilization or case management. This role will start on June 15th and will be in training throughout the rest of June and until the end of July (no time off during this time).
Requirements
- Associate or Bachelor's degree in nursing.
- RN License (active /unrestricted in state of residence).
- 5 to 7+ years of working with InterQual/MCG (Inpatient vs Observation).
- Utilization Management and/or Case Management.
- Critical Care background: ICU, Emergency Room, Cath Lab, Med Surg.
- Requires working knowledge of and applicable industry-based standards.
- Proficiency in Word, Access, Excel, TEAMS and other applications.
- Excellent written and verbal communication skills.
Nice To Haves
- Case Management Certification (preferred).
Responsibilities
- Analyzes and Audits Claims. Integrates medical chart severity of illness and intensity of service based on clinical guidelines and objectivity in performance of medical audit activities.
- Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
- Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.
- Meets or Exceed Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation (letter writing).
- Identifies New Claim Types. Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high quality, high value concept and or process improvement, tools, etc.
- Complete all responsibilities as outlined on annual Performance Plan.
- Complete all special projects and other duties as assigned.
- Must be able to perform duties with or without reasonable accommodation.
Benefits
- medical, dental, vision, disability, and life insurance coverage
- 401(k) savings plans
- paid family leave
- 9 paid holidays per year
- 17-27 days of Paid Time Off (PTO) per year
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
Number of Employees
1,001-5,000 employees
