Clinical Denial RN - Clinical Performance - FT - Day

Stormont Vail Health•Topeka, KS

9d•Hybrid

About The Position

The Clinical Denial RN performs clinical audit and validation processes to ensure medical record documentation and diagnosis coding for services provided are complete, compliant, and accurate, supporting appropriate reimbursement and quality standards. The role applies prospective and retrospective medical claims audit criteria and conducts clinical and financial reviews of records, including inpatient facility bills, provider offices and clinics, pharmacy, and other specialties, to verify that billed services were rendered, documented, and provided at the appropriate level. The RN identifies root causes of audit findings and recommends appropriate change management. The position works collaboratively with the Physician Advisor on documentation improvement and medical necessity principles. It reviews audit requests, interprets medical documentation, guides fellow auditors and staff, tracks audit results, educates internal departments, and advises the manager of utilization trends and quality-of-care concerns. The role is non-patient-facing, has no supervisory or budget responsibility, and may be performed in a hybrid arrangement subject to Stormont Vail’s remote-work guidelines.

Requirements

Three years of clinical experience in an acute care setting.
Registered Nurse license required through KSBN.
Bachelor of Science in Nursing (BSN) is preferred.

Nice To Haves

Bachelor of Science in Nursing (BSN).
CDI experience.

Responsibilities

Collaborate with the Physician Advisor on documentation improvement and medical necessity principles, applying objectivity in medical audit activity.
Perform root cause analysis and recommend change management when clinical validation audits or medical documentation indicate gaps in member access or provider involvement in managing chronic risk conditions.
Receive, review, verify, and process prospective and retrospective audit requests, including requests 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 solutions.
Provide clinical interpretation and guidance to fellow auditors and internal staff.
Maintain 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 possible under- or overutilization trends and other quality-of-care issues.
Maintain professional licenses and certifications.
Demonstrate knowledge of and follow the Kansas State Nurse Practice Act, including appropriate delegation of tasks and duties in coordinating health care team members, patient care, and department activities.
Comply with Stormont Vail Health policies, standards, mandatory training, and requirements, and perform other duties as assigned.