Clinical Appeals Nurse Auditor (RN) - Revenue Integri

A brief summary of what's ahead

Location:

Hutchinson Regional Medical Center

Full Time Equivalent (FTE):

1

Job position summary:

This position is responsible for the day to day review, coordination and management of Clinical denials requiring background and understanding from a Clinical, Operational and Payor logistical perspective. Auditor must work with a diverse group of other health care professionals to conduct review and appeal of Clinical denials related to all Payor plans. Clinical Nurse Case Auditor will evaluate trends and work as part of the Revenue Cycle team to develop meaningful information for the hospital to improve operational performance and cash collections. Nurse auditor must have knowledge of government – state and federal policies. The auditor should have strong project management and analytical skill that would enable to Nurse Auditor to successfully work on diverse projects simultaneously. Auditor should be able to work well individually and as part of a team. Assists with chart and defense audits with outside payers.

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.The benefits have never been more rewarding. Here are a few things we offer:

• Paid Parental Leave

• Tuition reimbursement

• Paid time off

• Holiday premium pay

• Shift and weekend differential pay

• 401k with a 6% employer match

• Medical, Dental, and Vision coverage

• Employee assistance program

Here is a look at the full job description:Clinical Appeals Nurse Auditor (RN) - Revenue Integri

GENERAL SUMMARY:

This position is responsible for the day to day review, coordination and management of Clinical denials requiring background and understanding from a Clinical, Operational and Payor logistical perspective.  Auditor must work with a diverse group of other health care professionals to conduct review and appeal of Clinical denials related to all Payor plans.  Clinical Nurse Case Auditor will evaluate trends and work as part of the Revenue Cycle team to develop meaningful information for the hospital to improve operational performance and cash collections.  Nurse auditor must have knowledge of government – state and federal policies.  The auditor should have strong project management and analytical skill that would enable to Nurse Auditor to successfully work on diverse projects simultaneously.  Auditor should be able to work well individually and as part of a team.  Assists with chart and defense audits with outside payers. 

           

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

ESSENTIAL FUNCTIONS:  

• Evaluates all Clinical denials, both pre and post submission, for possible overturn opportunity
  • Tracks trends electronically in the Compliance 360 program for effective management
  • Prepares appeals as necessary
  • Works closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts
• Works closely with Care Management, Health Information Management (HIM), and Patient Accounts to review cases and provide guidance in understanding the interplay between clinical and technical denials.
  • Educates Prior Auth team on key terms for obtaining a Prior Auth for high dollar or ‘at risk’ procedures that are trending on the denials tracking.
  • Educate Physician and other Clinical staff regarding changes in regulations and policies that impact reimbursement.
• Tracks and manages denied accounts, including triaging denials with Care Management, HIM, and Patient Accounts to quickly and expeditiously evaluate collectability
  • Works with Billing Specialist to meet all billing requirements when submitting an appeal or searching Payor resources for regulations
• Works creatively with Clinical professionals using job knowledge and experience to improve performance and recommendations on process improvements to avoid denials in the future
• Complies with Federal, State, and Local Laws that govern business practices
• Notes all activities in patient account and Compliance 360 for tracking, reporting and auditing purposes
• Leads the denials management meeting monthly and engages other departments as necessary
• Performs other job-related tasks, and special projects as assigned
• Assists Finance and Compliance with chart and defense audits by outside companies
• Provides accurate and timely written and verbal communication of instruction in a manner that is understood by all to solve difficult problems in the Denial Management forum.
• Regularly provides suggestions for quality improvement at any level to all personnel involved in the denial process and specifically to improve the functionality of the Denial team

MINIMUM KNOWLEDGE AND SKILLS REQUIRED:

• Must be a registered nurse (RN) in Kansas.

PREFERRED KNOWLEDGE AND SKILLS REQUIRED:

• 3 years of current experience in an acute care hospital setting.

REQUIRED BEHAVIORAL SKILLS:

• Integrity:
  • A personal presence which is characterized by a sense of honesty and the willingness to do the right thing.
  • The ability to role model, inspire and motivate others to promote the philosophy, mission, vision, goals and values of Hutchinson Regional Healthcare System.
• Compassion:
  • A personal presence which is characterized by a sense of caring that is reflected in a high level of empathy and customer service with all that we come in contact.
  • Ability to manage conflict, consider other points of view, and offer alternative solutions without jeopardizing overall project direction and the ability to manage customer expectations.
• Accountability:
  • Demonstrated track record of ownership of situations, projects and issues.
  • Able to work autonomously and have a high degree of flexibility to adapt to changing projects, priorities and work volumes.
• Respect:
  • Demonstrated ability to collaborate with a diverse population.
  • Treat all internal and external customers with a positive, proactive service orientation.
• Excellence:
  • Strong communication and presentation skills with a proven ability to influence and lead teams to conclusion/decision making.
  • Proven ability to think strategically but also must be able to lead day-to-day tactical processes.
  • Demonstrated ability to manage and provide coaching and leadership on complex projects.
  • Must be able to lead and/or facilitate process improvement.

MINIMUM EDUCATION AND EXPERIENCE REQUIRED:

• Associates degree in nursing

PREFERRED EDUCATION AND EXPERIENCE:

• degree related field

REQUIRED LICENSE/REGISTRATION/CERTIFICATION:

• Registered Nurse (RN) in Kansas

PREFERRED LICENSE/REGISTRATION/CERTIFICATION:

• N/A

We provide equal employment opportunities

Hutchinson Regional Healthcare System does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, marital status, veteran status, or any other status protected by applicable law. It is our policy to provide equal employment opportunities to all qualified individuals and to prohibit discrimination and harassment of any kind.

We participate in E-Verify

We will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the United States. If E-Verify cannot confirm that you are authorized to work, we are required to give you written instructions and an opportunity to contact the Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before we can take any action against you, including terminating your employment. We will only use E-Verify once you have accepted a job offer and completed form I-9.