Revenue Integrity Nurse Auditor

GENERAL SUMMARY

The Revenue Integrity Nurse Auditor is responsible for the auditing and compliance functions necessary to effect accurate and complete reimbursement to the health system from third party payers. Reports to the department leadership

ESSENTIAL DUTIES AND RESPONSIBILITIES

Ensures adherence to regulatory requirements related to billing and supporting documentation, as well as facilitates the completion of appeals in a timely manner.

Prepares trend and other reports for compliance audits and charge processes.

Serves as a resource to hospital departments regarding compliance with billing regulations and trends in denials of services due to medical necessity or appropriateness of services.

Conducts compliance, defense, LifeNet and special focus audits and reports findings.

Serves as a clinical resource for coding / denial management and customer service issues.

Participates as a member of the chargemaster team, providing clinical support and expertise on compliance related charge functioning.

Identifies and works collaboratively to correct discrepancies in patient charges.

Performs other duties as assigned.

LICENSES AND/OR CERTIFICATIONS

Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license.

Certified Professional Coder required.

Certified Outpatient Coder (COC; formerly CPC-H) required within 1 year of hire.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

Graduate of a Bachelors of Science in Nursing program required.

Minimum of 3 years of clinical experience as a Certified Professional Coder required.

Three to five years of case management utilization review, or compliance related work experience in a hospital setting preferred.

Pediatric experience preferred.

Current knowledge of third party billing, appeals, regulatory and accrediting requirements required.

Exceptional analytical skills necessary to determine appropriateness of patient charges in relation to medical records and third party reimbursement.

Interpersonal skills necessary in order to communicate effectively with other professionals.

Demonstrates proficiency in MS Office and other health record management systems.

Knowledge of quality management methodologies, medical record documentation, compliance requirements and performance improvement system.

Demonstrates the ability to prepare reports and summaries.

WORKING CONDITIONS

Normal office environment with little exposure to excessive noise, dust, temperature and the like.

PHYSICAL REQUIREMENTS

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