Stanford Health Care
Clinical Government Audit Analyst & Appeal Specialist II (RN) (Remote)
Stanford Health Care, Sacramento, California, United States, 95828
Clinical Government Audit Analyst & Appeal Specialist II (RN) (Remote)
Full‑time, Day – 08 Hour, Remote – USA.
Base pay range:
$62.75/hr – $83.16/hr (per hour).
Stanford Health Care – Revenue Cycle Denials Management Department.
What You Will Do
Adhere to Stanford Health Care’s organization competencies and Code of Conduct.
Denial Analysis: Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures. Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments, while identifying instances of overpayments and underpayments. Proficiency in healthcare claims analysis, including the ability to review, interpret, and evaluate claims data to identify trends, discrepancies, and opportunities for improvement.
Maintain accurate records of appeals and denials for tracking and reporting purposes.
Appeal Letter Drafting: Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records. Ensure compliance with Medicare, Medicaid, third‑party guidelines, Local Coverage Determinations (LCD), National Coverage Determinations (NCD), clinical documentation, coding guidelines, and payor policies to effectively challenge denials.
Appeal Strategies Development: Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials.
Submission of Appeals: Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines.
Appealability Scoring: Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal.
Proofreading and Editing: Review and edit appeals for clarity and accuracy prior to submission to ensure high‑quality presentation.
Audit Response: Ensuring the medical record documentation supports medical necessity and all services billed. Work closely with clinical teams, coding specialists, physicians and other departments to gather necessary information and clarify clinical documentation to support appeals.
Collaboration with Management: Identify and elevate denial patterns to the Manager of Government Audits and Appeals, providing detailed information for follow‑up and resolution.
Deadline Management: Complete all assigned tasks by established deadlines and communicate proactively with the Manager of Government Audit and Appeal regarding any potential barriers to timely completion.
Regulatory Compliance: Stay updated on changes in healthcare regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal controls related to documentation, coding, charging, and billing practices to ensure compliance.
Government Audit and Appeals Program Development: Actively participate in developing appeal templates, audit tools, goals, policies, and procedures for the Denials Management Department. Serve as a subject matter expert on billing and coding regulations and collaborate with team members on joint projects to enhance the framework.
Education Qualifications
Required: Bachelor’s degree in a work‑related discipline/field from an accredited college or university.
Experience Qualifications
Required: Minimum two (2) years of progressive denials and appeals experience.
Required Knowledge, Skills And Abilities
Ability to manage, organize, prioritize, multi‑task, and adapt to changing priorities while meeting deadlines.
Ability to communicate effectively in written and verbal formats including summarizing data and presenting results.
Extensive writing capabilities and efficiencies.
Ability to influence outcomes through convincing arguments supported by data.
Ability to apply critical thinking skills to identify patterns and trends.
Ability to mediate and solve complex work problems and issues.
Ability to effectively facilitate work groups to successful outcomes.
Knowledge of medical and insurance terminology, MS‑DRG, APR‑DRG, CPT, ICD coding structures, and billing forms (UB, 1500).
Experience with coding, clinical validation, and medical necessity for inpatient stays.
Knowledge of third‑party payor rules and regulations.
Knowledge of local, state, and federal healthcare regulations.
Knowledge of detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations, and standards, reach independent decisions and logical conclusions, and prepare reports of findings and recommendations.
Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust.
Ability to maintain confidentiality of sensitive information.
Ability to maintain competency and up‑to‑date knowledge of healthcare compliance, billing and coding requirements, practices, and trends.
Proficiency in computer systems, specifically EPIC and 3M.
Proficiency in computer software, including Microsoft Word, Excel, and Power Point.
Ability to adapt to changing priorities and shifts in denials and appeals activity while maintaining high standards of accuracy and compliance.
Demonstrated flexibility in responding to new challenges and evolving healthcare regulations.
Licenses and Certifications
CCA – Certified Coding Associate required within 180 days or
CCS – Certified Coding Specialist required within 180 days or
Certified Outpatient Coder – COC required within 180 days or
CDIP – Clinical Documentation Improvement Practitioner required within 180 days or
CCDS – Certified Clinical Document Specialist required within 180 days
RN – Registered Nurse – State licensure and/or compact state licensure required.
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non‑discrimination in all policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
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Base pay range:
$62.75/hr – $83.16/hr (per hour).
Stanford Health Care – Revenue Cycle Denials Management Department.
What You Will Do
Adhere to Stanford Health Care’s organization competencies and Code of Conduct.
Denial Analysis: Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures. Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments, while identifying instances of overpayments and underpayments. Proficiency in healthcare claims analysis, including the ability to review, interpret, and evaluate claims data to identify trends, discrepancies, and opportunities for improvement.
Maintain accurate records of appeals and denials for tracking and reporting purposes.
Appeal Letter Drafting: Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records. Ensure compliance with Medicare, Medicaid, third‑party guidelines, Local Coverage Determinations (LCD), National Coverage Determinations (NCD), clinical documentation, coding guidelines, and payor policies to effectively challenge denials.
Appeal Strategies Development: Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials.
Submission of Appeals: Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines.
Appealability Scoring: Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal.
Proofreading and Editing: Review and edit appeals for clarity and accuracy prior to submission to ensure high‑quality presentation.
Audit Response: Ensuring the medical record documentation supports medical necessity and all services billed. Work closely with clinical teams, coding specialists, physicians and other departments to gather necessary information and clarify clinical documentation to support appeals.
Collaboration with Management: Identify and elevate denial patterns to the Manager of Government Audits and Appeals, providing detailed information for follow‑up and resolution.
Deadline Management: Complete all assigned tasks by established deadlines and communicate proactively with the Manager of Government Audit and Appeal regarding any potential barriers to timely completion.
Regulatory Compliance: Stay updated on changes in healthcare regulations, payor policies, and industry best practices related to clinical appeals and denials management. Evaluate internal controls related to documentation, coding, charging, and billing practices to ensure compliance.
Government Audit and Appeals Program Development: Actively participate in developing appeal templates, audit tools, goals, policies, and procedures for the Denials Management Department. Serve as a subject matter expert on billing and coding regulations and collaborate with team members on joint projects to enhance the framework.
Education Qualifications
Required: Bachelor’s degree in a work‑related discipline/field from an accredited college or university.
Experience Qualifications
Required: Minimum two (2) years of progressive denials and appeals experience.
Required Knowledge, Skills And Abilities
Ability to manage, organize, prioritize, multi‑task, and adapt to changing priorities while meeting deadlines.
Ability to communicate effectively in written and verbal formats including summarizing data and presenting results.
Extensive writing capabilities and efficiencies.
Ability to influence outcomes through convincing arguments supported by data.
Ability to apply critical thinking skills to identify patterns and trends.
Ability to mediate and solve complex work problems and issues.
Ability to effectively facilitate work groups to successful outcomes.
Knowledge of medical and insurance terminology, MS‑DRG, APR‑DRG, CPT, ICD coding structures, and billing forms (UB, 1500).
Experience with coding, clinical validation, and medical necessity for inpatient stays.
Knowledge of third‑party payor rules and regulations.
Knowledge of local, state, and federal healthcare regulations.
Knowledge of detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations, and standards, reach independent decisions and logical conclusions, and prepare reports of findings and recommendations.
Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust.
Ability to maintain confidentiality of sensitive information.
Ability to maintain competency and up‑to‑date knowledge of healthcare compliance, billing and coding requirements, practices, and trends.
Proficiency in computer systems, specifically EPIC and 3M.
Proficiency in computer software, including Microsoft Word, Excel, and Power Point.
Ability to adapt to changing priorities and shifts in denials and appeals activity while maintaining high standards of accuracy and compliance.
Demonstrated flexibility in responding to new challenges and evolving healthcare regulations.
Licenses and Certifications
CCA – Certified Coding Associate required within 180 days or
CCS – Certified Coding Specialist required within 180 days or
Certified Outpatient Coder – COC required within 180 days or
CDIP – Clinical Documentation Improvement Practitioner required within 180 days or
CCDS – Certified Clinical Document Specialist required within 180 days
RN – Registered Nurse – State licensure and/or compact state licensure required.
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non‑discrimination in all policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
#J-18808-Ljbffr