| JOB SUMMARY
This RN position primarily serves in the capacity of auditing and reviewing the "Appeals and Grievances" that our Scott and White Health Plans receive from a variety of sources. While also referred to as the "Medical Nurse Auditor" from within our organization, the role is also expected to perform clinical reviews and provide input to our policies / procedures for our Medical Audit programs (associated with denials, appeals, grievances), insuring that our review and medical audit procedures are maintained, adhered to, and are compliant with state and national regulations.
ESSENTIAL FUNCTIONS OF THE ROLE
Develops a multi-faceted audit plans, including for Diagnosis-Related Group (DRG) and Ambulatory Payment Classifications (APC) validations, inpatient and outpatient hospital billing, skilled nursing facility audits, contract terms validations, high cost drug audits, itemized bill reviews and durable medical equipment audits. Monitors audit plans over time for continual processes improvement.
Analyzes current provider contractual arrangements to identify areas of risk and appropriate stratification. Develops a complete reimbursement validation program that addresses possible areas where payment errors or overcharges may be occurring based upon contractual language and reimbursement methodology.
Conducts reviews of medical records, charges and associated documentation, researching and applying knowledge related to billing and coding guidelines searching for billing, coding and unsupported (or clinical) documentation in provider billing.
Analyzes documentation to determine the accuracy and completeness of clinical and financial information maintained in support of charge reductions.
Validates the accuracy of claim billing, and subsequent payments to healthcare providers via medical audits. Alternatively, identifies billing errors and recovers overpayments for health claim payers to control health claims costs.
Develops a process for reviewing claims and rendering payment in timely manner, and creates an administrative hearing program for disputed audits as required.
Develops an appropriate communication tool with the providers regarding reduction in reimbursements.
Manages audit workflows, interacts at the audit and auditor level to ensure accuracy, timeliness and that results are consistent with state and federal regulations. Analyzes medical record documentation to ensure that coding and abstracted data is compliant with coding guidelines.
Provides education for external providers on correct billing practices and reviews specific audit issues; trains staff on coding issues and billing auditing. Ensure education and billing is compliant with payer requirements.
Maintains technical proficiency and remains current with the latest developments, advancements and trends in billing and coding compliance by attending educational programs, reading professional journals, actively participating professional organizations and maintaining certification.
KEY SUCCESS FACTORS
General clinical / nursing-level understanding of general health care modalities, therapies, terminology and equipment.
Ability to understand the customer's point of view and take ownership of creating a solution to their issues.
Knowledge and use of discharge planning, case management, utilization review and levels of care.
Knowledge of applicable federal and state regulatory requirements, including TDI, CMS, DOL, HHSC and NCQA standards and requirements.
Must be able to communicate thoughts clearly; both verbally and in writing.
Interpersonal skills to interact with a wide-range of constituencies.
Must have critical thinking and problem-solving skills.
Ability to balance multiple demands and respond to time constraints.
Ability to analyze, understand and act on detailed clinical care documentation.
General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.
Certified Coder or Certified Medical Audit Specialist (CMAS) preferred.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS
- EDUCATION - Associate's Degree
- MAJOR - Nursing
- EXPERIENCE - at least 3 Years of related RN Work Experience |
