Conifer Health Solutions
RN CRC Coding Auditor - REMOTE - $10K Sign On Bonus
Conifer Health Solutions, Frisco, Texas, United States, 75034
RN CRC Coding Auditor - REMOTE - $10K Sign On Bonus
The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims are coded and billed in accordance with nationally recognized coding guidelines, standards, regulations, and regulatory requirements, as well as payor and billing guidelines. Responses may include system documentation of findings and/or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.
The Auditor will perform analysis on clinical documentation, evidence-based criteria application outcomes, physician documentation, and physician advisor input, and will complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to CRC leadership. Provides expert application of evidence-based medical necessity review criteria tools. Works collaboratively to review, evaluate and improve the denial appeal process.
Essential Duties And Responsibilities
Formulates and submits letters of appeal. Creates effective appeals utilizing relevant clinical documentation from the medical record, supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, and applicable standards and protocols.
Performs reviews of accounts denied for DRG validation and DRG downgrades.
Documents in the appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, per-diems, DRG’s, Outlier Payments, and Stop Loss calculations.
Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.
Knowledge, Skills, Abilities
Effectively organizes work priorities
Demonstrates compliance with departmental safety and security policies and practices
Demonstrates critical thinking, analytical skills, and problem-solving abilities
Ability to handle multiple assignments and work independently with minimal supervision
Maintains accuracy at unit standard KPI goals
Excellent written and verbal communication skills
Detail oriented with ability to work independently and in a team
Moderate skills in MS Excel, PowerPoint, and MS Office
Ability to research difficult coding and documentation issues and follow through to resolution
Ability to work in a virtual setting under minimal supervision
Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes
Vaccinations Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to start of employment. This may include COVID-19 vaccination, influenza vaccination, and/or other required vaccines.
Education / Experience Education
Minimum Required:
Completion of BSN Degree Program or three years of experience with completion of BSN within five years of employment
RN License in the state of practice
Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement
Preferred/Desired:
Completion of BSN Degree Program
CCDS certification or inpatient coding certification
Experience
Minimum Required:
Three to five years clinical RN experience
Three to five years of Clinical Documentation Integrity experience
Expertise with InterQual and/or MCG Disease Management ideologies
Strong communication and interpersonal skills
Knowledge of CMS regulations
Knowledge of inpatient coding guidelines
1–2 years of current experience with reimbursement methodologies
Preferred/Desired:
Experience preparing appeals for clinical denials related to DRG assignment
Strong understanding of rules and guidelines including AHA’s Coding Clinics, AAMAS, CMS guidelines, state regulations, and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS
Certificates, Licenses, Registrations
Required:
RN
CCDS or related clinical documentation certification and/or AHIMA or AAPC coding credentials (CCS, CCA, CIC, CPC, or CPMA)
Preferred: BSN
Physical Demands The physical demands described here are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Lift 15-30 lbs
Travel approximately 10% of the time to client sites or other designated sites
Prolonged computer work for medical record quality reviews
Work Environment Office environment with typical desk and computer equipment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Other
Interaction with facility HIM and/or physician advisors
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
As part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry experience to clients in more than 135 local regions nationwide. We help clients strengthen their financial and clinical performance and succeed in the business of healthcare.
Compensation & Benefits Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience. Sign-on and relocation bonuses may be available for some roles.
Benefits include medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min 12 days per year
401k with up to 6% employer match
Health savings accounts and flexible spending accounts
Employee Assistance program and employee discounts
Voluntary benefits include pet, legal, accident and critical illness insurance
EEO statement: Employment practices will not be influenced by race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Note: This description reflects the responsibilities and requirements as of this posting and may be subject to change.
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The Auditor will perform analysis on clinical documentation, evidence-based criteria application outcomes, physician documentation, and physician advisor input, and will complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to CRC leadership. Provides expert application of evidence-based medical necessity review criteria tools. Works collaboratively to review, evaluate and improve the denial appeal process.
Essential Duties And Responsibilities
Formulates and submits letters of appeal. Creates effective appeals utilizing relevant clinical documentation from the medical record, supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, and applicable standards and protocols.
Performs reviews of accounts denied for DRG validation and DRG downgrades.
Documents in the appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, per-diems, DRG’s, Outlier Payments, and Stop Loss calculations.
Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.
Knowledge, Skills, Abilities
Effectively organizes work priorities
Demonstrates compliance with departmental safety and security policies and practices
Demonstrates critical thinking, analytical skills, and problem-solving abilities
Ability to handle multiple assignments and work independently with minimal supervision
Maintains accuracy at unit standard KPI goals
Excellent written and verbal communication skills
Detail oriented with ability to work independently and in a team
Moderate skills in MS Excel, PowerPoint, and MS Office
Ability to research difficult coding and documentation issues and follow through to resolution
Ability to work in a virtual setting under minimal supervision
Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes
Vaccinations Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to start of employment. This may include COVID-19 vaccination, influenza vaccination, and/or other required vaccines.
Education / Experience Education
Minimum Required:
Completion of BSN Degree Program or three years of experience with completion of BSN within five years of employment
RN License in the state of practice
Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement
Preferred/Desired:
Completion of BSN Degree Program
CCDS certification or inpatient coding certification
Experience
Minimum Required:
Three to five years clinical RN experience
Three to five years of Clinical Documentation Integrity experience
Expertise with InterQual and/or MCG Disease Management ideologies
Strong communication and interpersonal skills
Knowledge of CMS regulations
Knowledge of inpatient coding guidelines
1–2 years of current experience with reimbursement methodologies
Preferred/Desired:
Experience preparing appeals for clinical denials related to DRG assignment
Strong understanding of rules and guidelines including AHA’s Coding Clinics, AAMAS, CMS guidelines, state regulations, and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS
Certificates, Licenses, Registrations
Required:
RN
CCDS or related clinical documentation certification and/or AHIMA or AAPC coding credentials (CCS, CCA, CIC, CPC, or CPMA)
Preferred: BSN
Physical Demands The physical demands described here are representative of those that must be met to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Lift 15-30 lbs
Travel approximately 10% of the time to client sites or other designated sites
Prolonged computer work for medical record quality reviews
Work Environment Office environment with typical desk and computer equipment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Other
Interaction with facility HIM and/or physician advisors
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
As part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry experience to clients in more than 135 local regions nationwide. We help clients strengthen their financial and clinical performance and succeed in the business of healthcare.
Compensation & Benefits Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience. Sign-on and relocation bonuses may be available for some roles.
Benefits include medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min 12 days per year
401k with up to 6% employer match
Health savings accounts and flexible spending accounts
Employee Assistance program and employee discounts
Voluntary benefits include pet, legal, accident and critical illness insurance
EEO statement: Employment practices will not be influenced by race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Note: This description reflects the responsibilities and requirements as of this posting and may be subject to change.
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