Clinical Denial RN - Clinical Performance - FT - Day

Stormont-Vail HealthCare•Topeka, KS

7d•Hybrid

About The Position

Performs clinical audit and validation processes to ensure medical record documentation and diagnosis coding for services rendered are complete, compliant, and accurate, supporting appropriate reimbursement and quality standards. Applies prospective and retrospective medical claims audit criteria and conducts clinical and financial reviews of records, including inpatient facility bill audits, provider offices and clinics, pharmacy, and other specialties. Reviews whether billed services were rendered, documented, provided at the appropriate level, and met quality standards. Works collaboratively with the Physician Advisor on documentation improvement and medical necessity principles in medical audit activity, applying objectivity. Conducts root cause analysis and recommends change management based on audit findings. Reviews audit requests across a range of inpatient, outpatient, home health, equipment, rehabilitation, and pharmacy services; offers clinical guidance to auditors and internal staff; and educates relevant departments on audit outcomes. Maintains audit files and tracking databases, identifies utilization and quality-of-care trends, and contributes to process-improvement efforts. Maintains professional licensure and follows the Kansas State Nurse Practice Act, including appropriate delegation and coordination of care team members and department activities. This is a full-time, 40-hour-per-week, non-exempt position on the first/day shift. The role is not patient-facing and has hybrid remote-work capability. Remote work requires a quiet, distraction-free workspace that meets security and privacy standards, stable electricity, internet upload and download speed of at least 25 Mbps, full attention during working hours, adherence to agreed break and attendance schedules, and compliance with Stormont Vail’s Remote Worker Policy and annual Remote Work Agreement acknowledgment. The position has no supervisory or budget responsibility.

Requirements

Bachelor of Science in Nursing (BSN).
Registered Nurse license through KSBN.
Clinical Documentation Improvement (CDI) experience.
Follow the Kansas State Nurse Practice Act and its statutes and regulations.
Demonstrate appropriate delegation and coordination of health care team members, patient care, and department activities.
For remote work, maintain a quiet, distraction-free workspace compliant with security and privacy standards, stable electricity, and internet upload and download speed of at least 25 Mbps; follow agreed attendance and break schedules and Stormont Vail’s Remote Worker Policy.

Nice To Haves

Three years of clinical experience in an acute care setting.

Responsibilities

Perform prospective and retrospective clinical validation and medical claims audits to assess medical record documentation, diagnosis coding, billed services, and quality standards.
Collaborate with the Physician Advisor on documentation improvement and medical necessity principles, maintaining objectivity in medical audit activity.
Conduct root cause analysis and recommend change management when audit findings indicate documentation, access, or provider-involvement concerns related to chronic risk conditions.
Receive, review, verify, and process requests for audits involving inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care, durable medical equipment, rehabilitative therapies, and pharmacy reviews.
Provide feedback and process-improvement recommendations to health plan operations departments and participate in workgroups, committee meetings, and process-improvement activities.
Provide clinical interpretation and guidance to fellow auditors and internal staff.
Maintain audit files and enter information into databases to track and trend audit results.
Educate provider services, health services, finance, and other department staff about audit outcomes, and assist provider services with educational efforts.
Advise the manager of potential inappropriate utilization trends, including under- or over-utilization, and other quality-of-care issues.
Maintain professional license and certifications and comply with the Kansas State Nurse Practice Act, including appropriate delegation and coordination of care team members and department activities.
Comply with Stormont Vail Health policies, standards, mandatory training, and requirements; perform other duties as assigned.