Job Description:
The External Audit RN is responsible for the clinical medical necessity and level of care appeals for denials related to external audits by government and third-party payors. This role will actively manage, maintain, and communicate all levels of denial and appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity and level of care rationale for appeals.
1. Review and interpret governmental contractors’ response letter in comparison to the medical records.
2. Communicates with departmental stakeholders regarding missing or insufficient medical documentation.
3. Research and apply federal regulations, law, and relevant CMS policies as a basis for appeals.
4. Identifies and communicates root causes for denials with members of the healthcare team.
5. Assures all discussions and appeals are filed timely with appropriate clinical rationale.
6. Completes data entry in the audit databases for tracking, trends, and analysis.
7. Analyzes medical records using Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines to determine the viability of the appeal and to manage the appeal process.
8. Serves as a subject matter expert for documentation requirements, clinical disease processes and treatment, medical necessity decisions and appeal escalations.
9. Completes ongoing education and CEU requirements to maintain licensure and certifications.
Skills:
1. Results focused
2. Sound clinical judgement
3. Effective communication (both written and oral)
4. Detail-oriented
5. Analytical
6. Problem solving
7. Spreadsheets and related analysis
8. Collaboration
Qualifications:
1. Bachelor of Science in Nursing (BSN) preferred.
2. Current licensure as a registered nurse in state of practice.
3. Experience in Microsoft Office, electronic medical record systems and electronic databases.
4. Required: Three (3) years’ experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.
5. Preferred: Five (5) years’ experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.
Physical Requirements:
1. Interact with others requiring the employee to communicate information.
2. Operate computers and other office equipment requiring the ability to move fingers and hands.
3. See and read computer monitors and documents.
4. Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment.
5. Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment.
6. Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment.
7. May be expected to stand in a stationary position for an extended period of time.
Location: Peaks Regional Office
Work City: Broomfield
Work State: Colorado
Scheduled Weekly Hours: 40
The hourly range for this position is listed below. Actual hourly rate dependent upon experience.
$36.35 - $54.53
We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
All positions subject to close without notice.
#J-18808-Ljbffr