Job Description:

Description

This auditing role will focus on Clinical Chart Validation for our Short Stay & Readmission audits....this position may also flex in to other audit areas as needed. The ideal candidate for this position needs to have both clinical (RN) experience and a thorough understanding of: CMS inpatient and outpatient guidelines, clinical / medical necessity, re-admission and other policies experience. This position is responsible for auditing claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered.

Key Responsibilities:

- Audits Medical Records:

- Utilizes clinical & coding principles and client specific guidelines in performance of medical audit activities with short stay & readmission reviews.

- Draws on advanced clinical expertise and industry knowledge to substantiate conclusions.

- Performs work independently, reviews and interprets medical records and applies in-depth knowledge of clinical and some coding principles to determine potential issues.

- Effectively Utilizes Audit Tools

- Utilizes with advanced proficiency, Cotiviti clinical, encoder and audit tools required to perform duties.

- Enters the claim into Cotiviti system accurately and in accordance with standard procedures.

- Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals, accuracy and quality standards set by the audit for the auditing concept.

- Meets or Exceeds Standards/Guidelines for Quality

- Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.

- Identifies New Claim Types

- Identifies potential claims outside of the concept where additional recoveries may be available.

- Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.

- Recommends New Concepts and Processes

- Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience.

- Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction.

- Evaluates information and draws logical conclusions.

Requirements:

- Education (required)-

- Associates or Bachelor's degree in Nursing (active / unrestricted license)

- Certification (preferred)

- Case Management certification - preferred

- Outpatient or Inpatient Coding Credential - CCS, CPC or CIC - preferred

- Candidates who do not hold a coding credential will be given consideration but will need to obtain a coding certification within 1 year of their hire date in to the role.

- Experience

- Clinical experience required (experience in ER, critical care, OR, cath lab, or GI lab preferred)

- Case Management experience highly preferred

- High level of proficiency in Milliman and Interqual guidelines (as well as an understanding of the CMS inpatient only list)

- 3-5 years of medical record auditing or similar experience preferred

- Ability to utilize and analyze clinical auditing knowledge and skills to learn and become proficient in a variety of review types such as DRG, SNF, Home Health, DME, Hospice, Re-admissions, Short Stay and therapy reviews

- Adherence to official clinical or coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates.

- Requires working knowledge of and applicable industry based standards.

- Proficiency in Word, Access, Excel and other applications.

- Excellent written and verbal communication skills.

- Ability to work well in an individual and team environment.

Work Environment:

- Start date for this role is 1/4/21

- This is an at home-based position and you must have a work location within the continental US

- Interviewing & training will be done remotely.

- This position requires that you provide a high speed internet connection and a work environment free from distractions

- This role is aligned to certain productivity and quality requirements

#LI-JB1Qualifications

Education
Bachelors of Health Administration (preferred)
Associates of Health Administration (preferred)
Bachelors of Nursing (preferred)
Associates of Nursing (preferred)

Licenses & Certifications
CCDS: Cert Clin Doc Spec (preferred)
RN License (required)
RHIT: Heath Info Technic (preferred)
RHIA: Heath Info Admin (preferred)
CPC: Certified Prof Coder (preferred)
CCS: Cert Coding Spec (preferred)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c).

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