Clinical Denial RN - Clinical Performance - FT - Day

Clinical Audit/Validation Specialist

Performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered to patients is complete, compliant, and accurate to support optimal reimbursement and meet quality standards. Application of prospective and retrospective medical claims audit criteria, and clinical and financial review of medical records including but not limited to inpatient facility bill audits, provider offices and clinics, pharmacy and other specialties to ensure that services billed were rendered and documented, at the appropriate level, and meet quality standards. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management.

Education Qualifications

• Bachelor's Degree of Science in Nursing (BSN). Preferred

Experience Qualifications

• 3 years Clinical experience in an acute care setting. Required
• CDI experience. Preferred

Licenses and Certifications

• Registered Nurse - KSBN Required

What You Will Do

• Works collaboratively with the Physician Advisor to, documentation improvement, and medical necessity principles in performance of medical audit activity and applies principles of objectivity in performance of medical audit activity.
• Perform root cause analysis and submit recommendations for appropriate change management when clinical validation audits and interpretation of medical documentation indicates lack of member access and provider involvement to manage chronic risk conditions.
• Receives, reviews, verifies, and processes requests for prospective and retrospective audits including but not limited to 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 department.
• Provides feedback and process improvement recommendations to appropriate health plan operations departments and participates in workgroups/committee meetings and process.
• Provides clinical interpretation and guidance to fellow auditors and internal staff.
• Responsible for file maintenance including entry into database for tracking and trending audit results.
• Educates provider services, health services, finance, and other department staff on the outcomes of the audit results and assists provider services with educational efforts.
• Provides feedback and process improvement recommendations to appropriate health plan operations departments and participates in workgroups/committee meetings and process improvement solutions as required.
• Advises manager of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
• Maintains professional license and certifications Performs other functions as required.
• Demonstrates knowledge of the Kansas State Nurse Practice Act and follows the statutes and regulations therein.
• Demonstrates appropriate delegation of tasks and duties in the direction and coordination of health care team members, patient care and department activities in accordance with the Kansas State Nurse Practice Act.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
• Performs other duties as assigned

Patient Facing Options

• Position is Not Patient Facing

Remote Work Guidelines

• Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.
• Stable access to electricity and a minimum of 25mb upload and internet speed.
• Dedicate full attention to the job duties and communication with others during working hours.
• Adhere to break and attendance schedules agreed upon with supervisor.
• Abide by Stormont Vail's Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

• Hybrid

Scope

• No Supervisory Responsibility
• No Budget Responsibility

Physical Demands

• Balancing: Occasionally 1-3 Hours
• Carrying: Occasionally 1-3 Hours
• Climbing (Stairs): Rarely less than 1 hour
• Eye/Hand/Foot Coordination: Frequently 3-5 Hours
• Feeling: Occasionally 1-3 Hours
• Grasping (Fine Motor): Occasionally 1-3 Hours
• Grasping (Gross Hand): Occasionally 1-3 Hours
• Handling: Occasionally 1-3 Hours
• Hearing: Frequently 3-5 Hours
• Kneeling: Rarely less than 1 hour
• Lifting: Occasionally 1-3 Hours up to 10 lbs
• Pulling: Occasionally 1-3 Hours up to 10 lbs
• Pushing: Occasionally 1-3 Hours up to 10 lbs
• Reaching (Forward): Occasionally 1-3 Hours up to 10 lbs
• Reaching (Overhead): Rarely less than 1 hour up to 10 lbs
• Repetitive Motions: Frequently 3-5 Hours
• Sitting: Frequently 3-5 Hours
• Standing: Occasionally 1-3 Hours
• Stooping: Rarely less than 1 hour
• Talking: Frequently 3-5 Hours
• Walking: Occasionally 1-3 Hours

Working Conditions

• Noise/Sounds: Rarely less than 1 hour

Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.

Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.