Revenue Integrity Nurse Auditor

Summary

• Position Summary
  • The Revenue Integrity Nurse Auditor will be responsible for performing pre-billing and post-billing audits as assigned to ensure charge and claim accuracy and compliance.  RI Nurse Auditor is responsible for reviewing and appealing potentially denied charge line level services performed at St. Joseph's/Candler and its affiliates where applicable.. This position is the Revenue Integrity point of contact for Pharmacy and Pharmacy Financial Management applications through the Trisus software system, working through monthly reconciliation reports, software updates, and regular meetings with Pharmacy. Acts as Pharmacy liaison between Revenue Integrity, Pharmacy, and the Trisus software product.  The RI Nurse Auditor serves as a clinical expert within the Revenue Integrity department and for the Revenue Cycle team/leaders. The RI Nurse Auditor remains up to date with the various Centers of Medicare and Medicaid (CMS) and commercial/managed care insurance companies claim filing regulations, payer changes, regulatory updates; and monitors payer websites, newsletters, etc identifying  and communicating changes relevant to SJ/C clinical and revenue cycle teams.
• Education
  • Bachelor's of Science - Required
  • Medical Billing or Coding, Revenue Cycle Denials Management, Project Management and Healthcare Analytics - Preferred
• Experience
  • 2-3 Years Clinical experience - Required
  • 2-3 Years Hospital, Physician Revenue Cycle or Business Office, Clinical Documentation Improvement, Medical Coding, Health Information Services or a combination - Required
  • 3-5 Years Clinical Documentation Improvement - Preferred
• License & Certification
  • Registered Nurse License with State of Practice - Required
  • Medical Coding Certifications such as COC, CPC, CCDS-O or Certified Revenue Cycle Specialist (CRCS) or Certified Revenue Cycle Representative (CRCR) or similar certification – Required or obtain one within one year from date of hire
• Core Job Functions
  • Accurately reviews patient charges daily for correct coding and makes changes as necessary. Ensures accuracy of services/charges including units, CPT/HCPCs, modifiers and other key data elements as identified. Reviews clinical documentation to ensure appropriate charge capture.
  • Conducts pre-bill and post-billing audits of charges and coding to ensure accuracy, compliance and timeliness. Monitors accuracy of charge capture for emergency department facility visits, critical care services, procedures and infusion/injection, drug admin and blood administration and other areas as assigned. Provides training and guidance to clinical and revenue cycle staff regarding audit results and identified trends. 
  • Provides clinical and documentation expertise to revenue integrity and revenue cycle team members as it relates to appropriate patient charge capture and billing. Serves as department point of contact for managed care payers for charge line level denials and audits. Reviews post-billing payer audits and denials to identify and minimize charge line level avoidable denials. Participates in payor meetings to assist denials management and other revenue cycle leaders focusing on reducing of avoidable denials
  • Prepares and finalizes charge line level appeals, emergency room or other clinical service level downgrades; and may be assigned other denials or appeals as needed. Serves as liaison with third party vendors performing post-payment charge line level audits. Gathers and reviews documentation via Medical Record and other peripheral documentation from outside physicians and clinicians. Writes formal Reconsideration and Appeal Letters based on circumstances surrounding the denial and/or the patient’s clinical indications. Complies and submits required documentation for appeal. Follows up with payer provider representative for contract issues and claim disputes. Ensures appeals are completed and filed per payer time limits.  Documents all actions taken in appropriate computer systems.
  • Resolves Meditech tasks and account checks as assigned related to pharmacy, drug and blood admin, infusions and injections and other services provided by the infusion clinics and Oncology service line. May assist with other account checks charge entry, or tasks in Meditech as assigned.
  • Works with Pharmacy Business Manager to ensure appropriate charge capture, documentation and reimbursement using Trisus Pharmacy Financial Management and Pharmacy tools. Acts as Trisus Pharmacy liaison between Revenue Integrity, Pharmacy, and the Trisus software product managers/representatives. Evaluates denied and underpaid claims for drugs and drug administration for best possible approach to facilitate resolution.