Nurse Auditor

Lehigh Valley Health Network

1d•Remote

About The Position

Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day. Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network. Summary Functions as Hospital Liaison with Third Party billing and auditing firms for all audits for LVHN locations. Reviews all audits in LVHN audit software and writes appeals for charge and line item audit denials as well as level of care and medical necessity denials. Communicates audit results and develops action plan to reduce incidence of denials for LVHN. Provides explanation of hospital charges to inquiring patients. Participates in revenue recovery/revenue enhancement through the verification of correct charging procedures in EMR. Provides education to hospital departments to facilitate correct charges on all claims. Works with Physician Advisors on appeals to payors/third party vendor and documents their follow up in LVHN audit software and EMR. Collaborates with management team to participate with Insurance providers and third-party audit vendors to resolve audit appeal disputes or issues.

Requirements

Specialized Diploma in nursing
10 years clinical experience
Ability to read medical charts and identify deficiencies in documentation content.
Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
Knowledge of medical policy per payor guidelines.
Knowledge of Auth/Cert and utilization review and hospital departmental procedures.
Knowledge of where to look for coding of claims and interact with HIM when needed, Insurance knowledge of payor process and payment/audit rules.
Knowledge of Epic workflows with notes in account history and WQ Workflows.
Knowledge of hospital based charging methods such as charge tables, medical records and billing formats.
Intermediate knowledge of Excel and MS Word.
RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Nice To Haves

Bachelor’s Degree in nursing

Responsibilities

Creates an audit appeal letter to uphold the claim based on our charging practices or medical necessity documentation found in the EMR or coordinates and implements on site audits as required in lieu of a written appeal.
Coordinates audit appeals that need a physician’s input with the payor and sends claims to write off that have no further appeals.
Coordinates downgrade of class as directed by Physician Advisor for audited claims.
Facilitates write off accounts that cannot provide support for line item denials or level of care denials.
Looks for missing charges and investigates charges and usage to be sure correct charges are on the claim.
Identifies areas of incorrect charging practice, provides action plan to correct charging and does follow up auditing for compliance of action plan.
Provides monthly reporting, while working with clinical data support team, for action plans, line item audits and medical necessity audits.
Keeps all assigned work ques current that includes but are not limited to Gift of Life, Life threatening, OBV hours, bed charges.
Ensures compliance with regulatory and accrediting requirements.
Charge corrections and conversion accounts will be worked by this group.
Will complete special projects as assigned.