Regional Revenue Integrity Nurse Auditor- Hospital

POSITION OVERVIEW

Responsible for coordinating denials with Patient Business Service (PBS) center and ensures compliant and complete clinical documentation, assists with denials and related appeals, and identifies opportunities for revenue optimization.  Investigates denials and root causes, which includes performing thorough chart reviews, providing education to clinical colleagues and tracking of identified trends.   Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and applicable appeal data gathering.   Responsible for third party charge audits and trauma reviews.  May be require to travel between locations within the Region.

MINIMUM QUALIFICATIONS   

  • Registered Nurse and graduate of an accredited school of nursing plus at least four (4) years of nursing experience, including two (2) years of utilization review/case management, managed care or comparable patient payment processing experience.  Must have current registration with the State Board of Nursing Examiners or have a temporary permit to practice nursing in the assigned state. Bachelor's Degree preferred.  Must possess a demonstrated knowledge of revenue cycle and denial management functions
  • Knowledge of and experience in health care including government payers, applicable federal and state regulations, healthcare financing and managed care.
  • Knowledge of and experience in case management and utilization management.
  • Outpatient CDI experience preferred.
  • Knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required.  Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable. 
  • . Customer service background is required.  Working knowledge of Electronic Health Records (EHR) is preferred.  Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.
  • Possesses detailed understanding or aptitude to learn and understand denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons.
  • Must possess in-depth familiarity with third party billing requirements and regulations, and writing appeals.
  • Excellent verbal and written communication  and organizational abilities. Accuracy, attentiveness to detail and time management skills are required.
  • Must be comfortable operating in a collaborative, shared leadership environment. 
  • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.