Clinical Appeals Nurse Auditor (RN) - Revenue Integri
About The Position
This position is responsible for the day to day review, coordination and management of Clinical denials requiring background and understanding from a Clinical, Operational and Payor logistical perspective. Auditor must work with a diverse group of other health care professionals to conduct review and appeal of Clinical denials related to all Payor plans. Clinical Nurse Case Auditor will evaluate trends and work as part of the Revenue Cycle team to develop meaningful information for the hospital to improve operational performance and cash collections. Nurse auditor must have knowledge of government – state and federal policies. The auditor should have strong project management and analytical skill that would enable to Nurse Auditor to successfully work on diverse projects simultaneously. Auditor should be able to work well individually and as part of a team. Assists with chart and defense audits with outside payers. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
Requirements
- Must be a registered nurse (RN) in Kansas.
- Associates degree in nursing
- Registered Nurse (RN) in Kansas
Nice To Haves
- 3 years of current experience in an acute care hospital setting.
- degree related field
Responsibilities
- Evaluates all Clinical denials, both pre and post submission, for possible overturn opportunity
- Tracks trends electronically in the Compliance 360 program for effective management
- Prepares appeals as necessary
- Works closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts
- Works closely with Care Management, Health Information Management (HIM), and Patient Accounts to review cases and provide guidance in understanding the interplay between clinical and technical denials.
- Educates Prior Auth team on key terms for obtaining a Prior Auth for high dollar or ‘at risk’ procedures that are trending on the denials tracking.
- Educate Physician and other Clinical staff regarding changes in regulations and policies that impact reimbursement.
- Tracks and manages denied accounts, including triaging denials with Care Management, HIM, and Patient Accounts to quickly and expeditiously evaluate collectability
- Works with Billing Specialist to meet all billing requirements when submitting an appeal or searching Payor resources for regulations
- Works creatively with Clinical professionals using job knowledge and experience to improve performance and recommendations on process improvements to avoid denials in the future
- Complies with Federal, State, and Local Laws that govern business practices
- Notes all activities in patient account and Compliance 360 for tracking, reporting and auditing purposes
- Leads the denials management meeting monthly and engages other departments as necessary
- Performs other job-related tasks, and special projects as assigned
- Assists Finance and Compliance with chart and defense audits by outside companies
- Provides accurate and timely written and verbal communication of instruction in a manner that is understood by all to solve difficult problems in the Denial Management forum.
- Regularly provides suggestions for quality improvement at any level to all personnel involved in the denial process and specifically to improve the functionality of the Denial team
Benefits
- Paid Parental Leave
- Tuition reimbursement
- Paid time off
- Holiday premium pay
- Shift and weekend differential pay
- 401k with a 6% employer match
- Medical, Dental, and Vision coverage
- Employee assistance program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
