Governmental Audit Reviewer (LPN)

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The Governmental Audit Reviewer is responsible for the audit, submission, and appeal of clinical documentation associated with home health, hospice, LTACHs, and community based services, in response to external payer inquiries, denials, and requests for clinical documentation. Payer inquiries include, but are not limited to any and all pre and or post payment audits, such as: ADRs, CERTs, RACs, ZPICs, etc.

RN Degree Required

• Conducts thorough clinical review of Home Health, Hospice, Community Based Services, and LTACH documentation in response to governmental medical records requests such as: ADRs, RACs, CERTs, ZPICs, etc.
• Maintains a standardized approach to clinical review that maximizes inter-rater reliability.
• Composes professionally formatted letters for submission to the payer
• Is responsible and accountable for initial and if needed, final internal review determinations that establish the decision to appeal any external audit denials.
• Assists with the management of the appeal process of external review denials to include assignment of appeals and ensuring appeal deadlines are met.
• Prepares clinical documentation for and participates in Administrative Law Judge hearings to defend payment of denied claims.
• Maintains a current and working knowledge of relevant issues, laws and regulations through relevant websites, periodicals, seminars, training programs, and peer contact. This includes state and Federal regulations governing compliance and reimbursement.
• Maintains current knowledge of relevant LHC Group policies and procedures related to Compliance, Performance Improvement, Clinical Documentation, Internal Audit, etc
• Works with other LHC departments Directors and Managers to coordinate teams activities such that there is a minimum disruption to day-to-day operations.
• Works with established LHC processes to communicate trends based on audit findings to promote organization-wide corrective action and behavioral changes.
• Works with the Governmental Audit Supervisor to ensure government pay backs as determined through established audit process and procedure.
• Assist Governmental Audit Supervisor as needed with any additional Compliance Audits.
• Performs other duties as assigned.

• Formal Education: Bachelor's/Associates Degree
• Experience: 5 years
• License, Registration, and / or Certification Requirement: Current license and registration to practice as a licensed practical nurse or registered nurse.
• Degree in Nursing required.
• Minimum of one (1) to five (5) years experience in hospice, LTAC, and|or home health care, with current and working knowledge of reimbursement and compliance rules and regulations. Experience with auditing and analyzing clinical documentation preferred.

Skill Requirements

• Proficient skills in all Microsoft Office applications (Word, Excel, etc.).
• Evidence of leadership qualities and effective communication skills.
• Ability to relate and work well with others within each level of authority and responsibility.
• Ability to efficiently work independently and meet productivity expectations.
• Strong critical thinking skills.
• Ability to easily adapt to frequent process changes.