RN Clinical Auditor

Neighborhood Health Plan of Rhode Island•Smithfield, RI

7d•Onsite

About The Position

The RN Clinical Auditor conducts comprehensive reviews of claim data and medical record documentation for Fraud, Waste, and Abuse (FWA) investigations opened by the Special Investigations Unit (SIU). The role uses computer-based data-mining tools, claim payment systems, and case-management systems to identify aberrant or potentially fraudulent billing patterns. The auditor obtains and reviews medical records to validate that authorized, billed, and paid services were provided in accordance with State and Federal regulations and guidelines, Neighborhood benefit coverage and payment policies, medical necessity, and standards of care. The position works collaboratively with the SIU team and communicates with internal business areas and, as necessary, external State and Federal regulatory and law-enforcement agencies. The auditor manages casework independently, maintains documentation in accordance with SIU procedures, and supports reporting, education, and legal proceedings as required.

Requirements

Registered Nurse with an active, current, unrestricted Rhode Island license in good standing.
At least three years of experience in healthcare coding directly related to determining appropriate diagnosis, procedure, and other billing codes; utilization management; medical record auditing; or healthcare quality improvement.
Knowledge of clinical medical record documentation requirements.
High-level knowledge of medical terminology.
Proficiency with technology software tools, including Microsoft Office.
Excellent written and verbal communication skills and strong attention to detail.
Ability to maintain confidentiality.
Ability to take direction and support a multitude of individuals.
Ability to work independently and prioritize activities.

Nice To Haves

Working knowledge of fraud, waste, and abuse policies and practices.
Expertise in evaluation and management coding and auditing.
Knowledge of Behavioral Health billing and coding guidelines and/or regulatory guidelines.
Electronic medical record review experience.
Electronic investigative case-management and/or healthcare claims data-mining tool experience.
Certified Coding Specialist (CCS), Certified Coding Specialist Provider-based (CCS-P), Certified Professional Coder (CPC or CPC-H), CPMA, or equivalent certification.
Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification.

Responsibilities

Plan and perform audits and investigations to detect and prevent fraud, waste, and abuse using knowledge of CPT, ICD, and HCPS coding guidelines and regulations, benefit coverage, and clinical and payment policies.
Use data-mining tools to identify outliers and potential case leads.
Identify aberrant billing patterns that result in overpayments or potential fraudulent activity.
Obtain and review medical records and prepare comprehensive clinical review and investigative summaries according to SIU procedures.
Notify providers of findings and provide feedback and education as necessary.
Respond to appeals and prepare settlement agreements.
Provide accurate reporting to recoupment staff to initiate recovery of overpayments.
Refer cases to the Legal department as necessary for assistance with recoveries from non-responsive providers.
Manage caseloads independently, meet established timelines, and ensure timely follow-up, audit completion, and submission of recoupments and/or fraud allegations to regulatory oversight agencies.
Maintain casework documentation according to SIU policies and procedures to support mandated Core Contract reporting for EOHHS.
Collaborate with management, SIU and Compliance team members, internal business leads, and external agencies as necessary, and provide investigation progress updates.
Communicate investigative findings and provide testimony in legal proceedings as required.
Assist with requests for information from external regulatory and law-enforcement agencies.
Assist with fraud and abuse awareness, detection, and reporting education for business areas as required.
Take responsibility for professional development, support a learning environment, and meet professional competency requirements.
Perform other duties as assigned.