Nurse Auditor Revenue Integrity Specialist

Job Title

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Coordinate, supervise, and respond to third-party patient bill audits. Perform patient-requested audits in a timely manner. Perform random quality audits as schedule permits.
• Assist Patient Account personnel with patient questions about itemized charges.
• Maintain reporting systems for audit activities and identify patterns and trends in results.
• Act as a resource for all hospital departments regarding charging questions and issues.
• Routinely review inpatient and outpatient records for appropriate coding and charging.
• Provide educational sessions for revenue-producing departments regarding appropriate charging processes and procedures.
• Work cooperatively with the Patient Accounting staff and other healthcare professionals in obtaining correct HCPCS codes and modifiers.
• Assist the Health Information Department with RAC requests, coding reviews, and denials.
• Ensure accuracy and integrity of charge data prior to billing interface and claims submission.
• Utilize a computerized encoding system to facilitate accurate coding and sequence diagnoses and procedures by following ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.
• Report trends and improvements to the Director of Patient Accounts regarding assigned HCPCS codes and modifiers.
• Receive, review, verify, and process requests for chart audits of inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews from Finance and/or Claims departments.
• Prepare written reports for Finance and Claims departments, including explanations for recovery of monies and appropriate regulatory agencies.
• Educate Provider Services, Claims, Recovery, Finance, and other department staff on audit outcomes and assist Provider Services with educational efforts.
• Provide feedback and process improvement recommendations to appropriate hospital departments and committees based on analysis and trending of hospital or provider audits.
• Provide written explanations to patients questioning their bills. Must be able to communicate effectively, both verbally and in writing, with clinical and non-clinical staff and individuals.
• Be familiar with coding diagnostic and procedural information from the medical record using ICD-10-CM and CPT-4/HCPCS classification systems. Utilize a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.
• Consistently maintain established productivity requirements and achieve a 96% or greater accuracy rate.
• Attend hospital-wide orientation, in-services, educational meetings, and other meetings as required.
• Attend continuing education functions as necessary to maintain credentials, regardless of whether educational programs are supported by the department budget.
• Exhibit excellent customer relations with patients, visitors, physicians, and co-workers.
• Show courtesy, compassion, honesty, and respect for others in adherence to the Hospital's mission, philosophy, and policies for promoting a positive work and customer environment.
• Adhere to CRMC's confidentiality policy for all information related to patients, families and friends, hospital employees, physicians, and clients.
• Maintain effective interdepartmental communication.
• Attend required hospital-wide orientations, meetings, and in-services.
• Demonstrate a commitment to flexible work scheduling when necessary.

Education and Experience

Minimum Required Education: Graduate of an approved school of professional nursing. Preferred Education: Bachelor of Science in Nursing (BSN) preferred. Experience: Senior-level coding experience with at least five years of recent coding experience in an acute hospital setting is required, with coding ability demonstrated through a skills assessment; or five years of experience as an intensive care unit nurse, emergency department nurse, or documentation specialist nurse auditor. Experience with health information systems and computer technology is required. Must possess the ability to communicate effectively, both verbally and in writing, and work independently with strong attention to detail and accuracy.

Certificates, Licenses, Registrations

• Current Virginia Registered Nurse (RN) License.

Qualifications

Education: Bachelors or better in Nursing. Technical/other training or better in Nursing.

Licenses & Certifications: Required Registered Nurse

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.