NURSE AUDITOR * Job in Pasadena, California Us

The Nurse Auditor works in Managed Care Recovery Unit (MCRU) to provide hands on guidance, support and direction on opportunities surrounding medical necessity, medical management, and charge audits as it impacts recovery efforts. Also, works with MCRU and other CHW departments to identify process improvement wih the goal of accelerating cash and preventing avoidable denials.

The Nurse Auditor examines government reimbursement guidelines, managed care contract language and actual payment practices related to medical management to determine if CHW facilities are receiving appropriate payment based upon services rendered and contractual terms and conditions.

ESSENTIAL FUNCTIONS:
* Performs independent and team oriented financial and clinical analysis to determine sources of delays, denials, and underpayments due to medical management and medical necessity issues.

*Reviews patient accounts including, medical billing and payment documentation to determine sources of recovery opportunities

* Assists Director in communicating MCRU efforts to business offices as well as advising them of process improvements along the revenue cycle.

* Assists Director in communicating applicable contract language and revenue cycle process improvements to clinical and medical management staff

* Apply clinical criteria to support recovery efforts.

* Provide input on impact of medical management/UR contract language.

* Appeals denials, down coding and disputes charges by reviewing medical documentation and health plan explanation of benefit responses. Recommends process improvement to CHW entities to reduce recurring denials and improve accepted charges.

*Identify opportunities, document findings, and recommend solutions to improve system-wide or hospital-specific processes related to medical management, medical necessity, and clinical documentation
Perform audits of third party payer utilization management requirements and practices, and CHW Facility compliance with authorization and UM obligations

* Provide education to CHW Facilities on UM best practices and clinical appeal strategies to address payer clinical denials

* Support CHW system conversions through related audits, charge/order validations, and other audits as may be necessary to ensure smooth system implementations

QUALIFICATIONS:

* RN (preferred) or LVN with comparable experience and background. Certified Case Manager or Certified Professional in Healthcare Quality (CPHQ) or CMAS certification preferred.

* 5+ years of acute care and/or health plan clinical experience, preferably within a hospital setting

* 1+ years experience reviewing medical management and medical necessity areas with managed care payers

* Possess knowledge and experience with national clinical criteria applied in case management, including Interqual Milliman, standards

* Working knowledge of billing codes, such as RBRVS, CPT, ICD-9, and DRG. Experience with Case Management software such as MIDAS preferred.

* Experience and knowledge of managed care contracts, accounts receivable and revenue cycle functions

* Working knowledge of provider billing guidelines, payer reimbursement policies and related industry based standards

* Success with appealing managed care denials and underpayment decisions based upon clinical indicators

* Ability to examine financial and clinical data trends and work with other Unit team members to report, identify and recommend action steps to resolve payment problems

* Ability to prioritize and manage multiple tasks with efficiency

Moderate travel may be required to visit facilities to examine medical documentation and meet with hospital personnel, and to attend necessary training or seminars.

~cb~06-14-2011
~M~05-26-2011