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Revenue Nurse Auditor-E - PSJH

Company: St. Joseph Health / Covenant Health
Location: Orange
Posted on: March 28, 2020

Job Description:

We are looking for a Revenue Nurse Auditor-E - PSJH with Revenue Integrity at Revenue Cycle Services LLC.Location: Orange, California (Remote/Virtual Position)Schedule: Full time - BiweeklyShift: 8-Hour, DaysJob Summary:The Nurse Auditor is responsible for providing patient focused, standardized, compliant revenue cycle support that will assist Providence St Joseph Health to in meeting financial objectives.Conduct audits (individual chart/bill audits, focus audits, compliance audits, payer defense audits and patient requests for audit). Review and assess the accuracy of charges and CPT/HCPCS coding, the documentation of orders and clinical documentation to support charges, and the processes used by the ancillary departments for insuring charge capture and appropriate documentation. Analyze audit results and report findings to promote and improve compliant processes. Assist in the research and coordination of compliance related information for the compliance program. Provide recommendations to align with best practices. Appeal and manage the lack of payment (denials) from insurance plans (Payors). Work collaboratively with the Payors, RCS, Case Management, Admitting and Medical Records to resolve existing denials and maximize processes to reduce future denials for accurate and timely reimbursement. Educate ministries on regulatory procedures to maintain compliance and integrity of the revenue cycle and charge capture. Serve as Subject Matter Expert on multiple processes and procedures to assist management with projects relating to the Compliance program.The Nurse Auditor performs all duties in a manner that promotes Providence St. Joseph mission, values, and philosophy. In all aspects, he/she serves as a role model for the values and mission of the organization.Essential Functions:

  • Independently conduct revenue audits including bill audits, focus audits, compliance audits, government audits and patient requests. Gather and review all necessary clinical documentation and compare to the final edited bill. Use clinical expertise and knowledge of Medicare or payer billing requirements, to evaluate the accuracy of billed charges and hospitals compliance with Medicare and other billing rules.
  • Develop, monitor, and report key measurements, trends and audit results to RI-CDM management.
  • Collaborate with facilities to identify minimum specifications and/or processes each need in place to support compliant and accurate clinical documentation that supports medical necessity and other regulatory requirements.
  • Collaborate with facilities to identify and develop needed resources to provide education and evaluation of clinical documentation.
  • Interpret and communicate regulatory standards and their implications to clinicians and key internal constituents.
  • Document and communicate recurring problems, including business impact and possible resolutions.
  • Take initiative in investigating and resolving claim and charging issues.
  • Independently address patient, department and administrative requests for a variety of issues related to revenue and charge integrity.
  • Reduce reporting variations by working with business office departments to identify issues impeding accurate, timely and relevant reporting.
  • Manage payer denials after the Hospital PFS or Case Manager identifies the denial by gathering/reviewing all necessary clinical & non-clinical documentation.
  • Review recommendations as subject matter expert to ensure recommendations are sustainable.
  • Work with RI-CDM Dept and Internal Audit, providing audit related assistance as needed.
  • Investigate medical record and charge entry discrepancies, analyze information, and make recommendations for corrections or process improvements.
  • Serve as a primary revenue integrity resource and liaison for charge producing departments, RBO, HIM-Coding, Case Management and Admitting.
  • Other duties as assigned.Minimum Position Qualifications:
    • Associate's Degree or Bachelor's Degree in Nursing.
    • 5 years clinical experience in an acute care setting.
    • 3 years experience actively utilizing MEDITECH/EPIC and the reporting functions.
    • Excellent organizational skills.
    • Ability to work within tight timeframes and meet strict deadlines.
    • Certified Nurse, upon hirePreferred Position Qualifications:
      • Master's Degree in Nursing, Health Care Administration, or equivalent.
      • 1 year experience in a multi-hospital and/or integrated healthcare system.
      • 3 years Minimum 3 years working in case management or similar function in an acute care setting.
      • 1 year Familiarity with Revenue Cycle processes.
      • Case Management Healthcare Professional, upon hireSt. Joseph Health (SJH) is an integrated healthcare delivery system sponsored by the St. Joseph Health Ministry and organized into three regions: Northern California, Southern California, West Texas/Eastern New Mexico.SJH provides a full range of care from facilities including 14 acute care hospitals, home health agencies, hospice care, outpatient services, skilled nursing facilities, community clinics, and physician organizations.SJH maintains a 'continuum of care,' matched to the diverse needs of the urban centers, smaller cities and rural communities in three statesFor the third year in a row in 2009, the Gallup Organization awarded St. Joseph Health its highest honor - the Great Workplace Award.SJH provides exceptional benefits, opportunities for advancement and relocation within the system.St. Joseph Health is comprised of four core values: Service, Excellence, Dignity, and Justice are the guiding principles of all we do.Excellent compensation program and benefits provided.St. Joseph Health (SJH) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics.In addition to federal law requirements, St. Joseph Health (SJH) complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.Positions specified as on call, per diem refers to employment consisting of shifts scheduled on as as needed basis to fill in for staff vacancies.Company: SJH System OfficeCategory: Clinical Informatics

Keywords: St. Joseph Health / Covenant Health, Orange , Revenue Nurse Auditor-E - PSJH, Accounting, Auditing , Orange, California

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