Nurse Auditor

Job description

JOB SUMMARY:

The Nurse Auditor will have full responsibility to audit patient charts (i.e., medical record) and respond to insurance denials. The audit is conducted to ensure that the clinical documentation contained within the patient chart supports items and services that appear on the patient's bill, and to ensure that all items and services provided are included on the patient bill. Where clinical documentation does not support items appearing on the bill, the Nurse Auditor will prepare a report of exceptions and offer solutions. The Nurse Auditor will ensure complete and timely responses to the requestor of the audit.

QUALIFICATIONS:

Associates or Bachelor of Science in Nursing required.

Strong Computer and software skills required for effective remote work.

Registered Nurse licensed in New York preferred.

3+ years' experience in hospital setting preferred.

Auditing experience preferred.

Knowledge of CPT/HCPCS procedural coding and Charge Description Masters strongly preferred.

Experience with PCs, word processing, spreadsheet, graphics, and database software applications is desired.

Ability to work independently & cooperatively, efficiently, and accurately prioritizing varying workloads required.

Strong quantitative, analytical, and organization skills required.

Must be able to understand all ancillary department functions.

Must be able to understand insurance terms (i.e. HMO/PP, EOB, stop loss, etc.) and payment methodologies. Excellent communication skills required. Positive attitude to work effectively with staff and clients required.

SPECIFIC ESSENTIAL FUNCTIONS:

Additional Skill Set(s) Required:

1. Coordinates all procedural and other elements related to the Centers for Medicare & Medicaid Recovery Audit Contractor program, commercial payor audits, patient requested audits and charge capture auditing.

2. Audits and reconciles services and items included in the patient's chart with services and items included on the patient's bill in a timely manner. Where exceptions are noted, suggested solutions are offered.

3. Identifies and prepares charges to be corrected on accounts.

4. Pre-reviews accounts being audited by Government Agencies.

5. Meets required timelines for all audit activities.

6. Works fluidly with Audit Team to communicate audit results.

7. Reviews medical records for accuracy and billing compliance as support for billers and coders, for medical necessity and where appropriate works through the hospital HIM and financial departments to identify physician and clinic practices that require improved documentation.

8. Organizes and reconciles daily work drivers to ensure accountability of all audits assigned and to ensure audits are worked in proper priority.

9. Keeps updated on various billing rules to ensure charges that are identified in audits are split and rebilled properly.

10. Conducts trend analyses to identify patterns in audit requests and outcomes for medical necessity, coding and billing practices.

11. Functions as a liaison to resolve any related charge/coding issues or problems that occur in or are identified during the audit process.

12. Instructs and teaches. Performs ancillary service quality assurance reviews and audits, and meets with the Managers and staff to instruct and inform on documentation findings to increase accuracy in billing; recommends solutions to improve charge capture accuracy.

13. Excellent communication skills necessary to deal with many departments regarding billing issues and required solutions.

14. Performs other duties as assigned.

Job Type: Full-time

Pay: From $87,000.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Flexible schedule
Health insurance
Life insurance
Paid time off
Vision insurance
Schedule:

Monday to Friday
License/Certification:

RN License (Required)
Ability to Relocate:

West Hempstead, NY 11552: Relocate before starting work (Required)
Work Location: Hybrid remote in West Hempstead, NY 11552