Clinical Appeal Revenue Integrity Nurse Auditor

CentraState Healthcare System•Freehold, NJ

4d•Onsite

About The Position

This role is responsible for auditing documentation, ensuring documentation meets medical necessity requirements, constructs appeal letters, following all federal, state and payer requirements. They serve as a liaison between clinical, coding, billing, compliance, and finance teams to promote best practices in revenue cycle operations. They will work with hospital departments including Case Management/Utilization Review, Health Information Management, Patient Financial Services, Ancillary Departments, Physicians and Nursing. They will analyze audit trends, communicate findings and collaborate with Revenue Cycle on goals and opportunities for improvement.

Requirements

Bachelor's degree in Nursing required.
Minimum of 3-5 years of RN clinical experience required, acute care preferred.
Current NJ RN License required.
Strong understanding of medical necessity criteria, clinical documentation standards, and revenue cycle processes.
Strong Clinical judgement and analytical skills
High attention to detail and accuracy
Excellent written and verbal communication
Ability to interpret regulatory and payer guidance
Strong collaboration and relationship-building skills to effectively relate with all members of the healthcare team
Ability to manage multiple priorities independently
Proficiency with EPIC, Microsoft Office (Excel, Word, PowerPoint)

Responsibilities

Review clinical denials and identify root causes
Write clinical appeal letters and medical necessity reviews
Write and submit thorough, concise, fact-based appeals to insurance companies when a service has been denied or unpaid
Partner with Revenue Cycle Team in methods of denials prevention
Conduct education and presentations re: denials for hospital wide denials prevention
Track and trend denial patterns and work collaboratively on actions plans to reduce denials
Conduct prospective and retrospective audits related to coding, billing and clinical documentation
Identify trends related to underpayment, overpayment or denials
Ensure compliance with Medicare, Medicaid and commercial payor guidelines and all state and federal regulations
Assist in responding to payor audits, internal audits and compliance investigations
Review clinical documentation to ensure accuracy, completeness, and compliance with regulatory and payer requirements
Identify documentation gaps affecting reimbursement and quality reporting
Collaborate with Physicians, Nurses, CDI and Coding teams on denials prevention
Support correct assignment of ICD-10, CPT and charge codes
Provide education on best practices and regulatory requirements of documentation
Analyze data and identify revenue integrity risks, trends, and improvement opportunities
Prepare reports and dashboards related to audit findings, denials and compliance metrics
Support leadership with recommendations for process improvement initiatives
Join and participate in national organizations to educate and improve appeal decisions and processes
Performs other responsibilities within the revenue integrity departments as assigned

Benefits

Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members)
Life & AD&D Insurance
Long-Term Disability (with options to supplement)
403(b) Retirement Plan with employer match
401(a) Retirement Plan with employer contribution
PTO
Tuition Reimbursement
Well-Being Rewards
Employee Assistance Program (EAP)
Fertility Coverage, Healthy Pregnancy Program
Flexible Spending & Commuter Accounts
Pet, Home & Auto, Identity Theft and Legal Insurance
Growth Opportunity and Workforce Development Initiatives
Continuing Education / Onsite Training
A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
Concierge Services with Work & Family Benefits