Medical Auditor RN, (Utilization Review, Appeals)
Company: Baylor Scott & White Health
Posted on: April 3, 2021
This RN position primarily serves in the capacity of auditing and
reviewing the "Appeals and Grievances" that our Scott and White
Health Plans receive from a variety of sources. While also referred
to as the "Medical Nurse Auditor" from within our organization, the
role is also expected to perform clinical reviews and provide input
to our policies / procedures for our Medical Audit programs
(associated with denials, appeals, grievances), insuring that our
review and medical audit procedures are maintained, adhered to, and
are compliant with state and national regulations.
ESSENTIAL FUNCTIONS OF THE ROLE
Develops a multi-faceted audit plans, including for
Diagnosis-Related Group (DRG) and Ambulatory Payment
Classifications (APC) validations, inpatient and outpatient
hospital billing, skilled nursing facility audits, contract terms
validations, high cost drug audits, itemized bill reviews and
durable medical equipment audits. Monitors audit plans over time
for continual processes improvement.
Analyzes current provider contractual arrangements to identify
areas of risk and appropriate stratification. Develops a complete
reimbursement validation program that addresses possible areas
where payment errors or overcharges may be occurring based upon
contractual language and reimbursement methodology.
Conducts reviews of medical records, charges and associated
documentation, researching and applying knowledge related to
billing and coding guidelines searching for billing, coding and
unsupported (or clinical) documentation in provider billing.
Analyzes documentation to determine the accuracy and completeness
of clinical and financial information maintained in support of
Validates the accuracy of claim billing, and subsequent payments to
healthcare providers via medical audits. Alternatively, identifies
billing errors and recovers overpayments for health claim payers to
control health claims costs.
Develops a process for reviewing claims and rendering payment in
timely manner, and creates an administrative hearing program for
disputed audits as required.
Develops an appropriate communication tool with the providers
regarding reduction in reimbursements.
Manages audit workflows, interacts at the audit and auditor level
to ensure accuracy, timeliness and that results are consistent with
state and federal regulations. Analyzes medical record
documentation to ensure that coding and abstracted data is
compliant with coding guidelines.
Provides education for external providers on correct billing
practices and reviews specific audit issues; trains staff on coding
issues and billing auditing. Ensure education and billing is
compliant with payer requirements.
Maintains technical proficiency and remains current with the latest
developments, advancements and trends in billing and coding
compliance by attending educational programs, reading professional
journals, actively participating professional organizations and
KEY SUCCESS FACTORS
General clinical / nursing-level understanding of general health
care modalities, therapies, terminology and equipment.
Ability to understand the customer's point of view and take
ownership of creating a solution to their issues.
Knowledge and use of discharge planning, case management,
utilization review and levels of care.
Knowledge of applicable federal and state regulatory requirements,
including TDI, CMS, DOL, HHSC and NCQA standards and
Must be able to communicate thoughts clearly; both verbally and in
Interpersonal skills to interact with a wide-range of
Must have critical thinking and problem-solving skills.
Ability to balance multiple demands and respond to time
Ability to analyze, understand and act on detailed clinical care
General computer skills, including but not limited to: Microsoft
Office, information security, scheduling and payroll systems,
electronic medical documentation, and email.
Certified Coder or Certified Medical Audit Specialist (CMAS)
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - Associate's Degree
- MAJOR - Nursing
- EXPERIENCE - at least 3 Years of related RN Work Experience
Keywords: Baylor Scott & White Health, Temple , Medical Auditor RN, (Utilization Review, Appeals), Healthcare , Temple, Texas
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