Registered Nurse CRC Coding Auditor - REMOTE

Conifer Revenue Cycle Solutions • Frisco, TX

120d • $56,784 - $85,176 • Remote

About The Position

The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and/or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted. The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.

Requirements

• Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment.
• RN License in the State of Practice.
• Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
• Three to Five years Clinical RN Experience.
• Three to Five years of Clinical Documentation Integrity experience.
• Must have expertise with Interqual and/or MCG Disease Management Ideologies.
• Strong communication (verbal/written) and interpersonal skills.
• Knowledge of CMS regulations.
• Knowledge of inpatient coding guidelines.
• 1-2 years of current experience with reimbursement methodologies.

Nice To Haves

• Completion of BSN Degree Program.
• CCDS certification or inpatient coding certification.
• Experience preparing appeals for clinical denials related to DRG assignment.
• Strong understanding of rules and guidelines, including AHA's Coding Clinics, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process.
• Working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS.

Responsibilities

• Formulates and submits letters of appeal.
• Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in appropriate denial tracking tool (ACE).
• Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG's, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

Benefits

• Medical, dental, vision, disability, life, and business travel insurance.
• Paid time off (vacation & sick leave) - min of 12 days per year, accrued at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match.
• 10 paid holidays per year.
• Health savings accounts, healthcare & dependent flexible spending accounts.
• Employee Assistance program, Employee discount program.
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree