Tenet Healthcare
RN CRC Coding Auditor - Remote - $10K Sign On Bonus
Tenet Healthcare, Frisco, Texas, United States, 75034
JOB SUMMARY
The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will elevate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.
The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and 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 the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.
ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned.
Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.
Performs reviews of accounts denied for DRG validation and DRG downgrades.
Documents in 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 To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Effectively organizes work priorities
Demonstrates compliance with departmental safety and security policies and practices
Demonstrates critical thinking, analytical skills, and ability to resolve problems
Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
Possesses excellent written and verbal communication skills
Detail oriented and ability to work independently and in a team setting
Moderate skills in MS Excel and PowerPoint, 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
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE Education
Minimum Required:
Completion of BSN Degree Program or three years of experience and 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
Must have expertise with Interqual and/or MCG Disease Management Ideologies
Strong communication (verbal/written) 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, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS
CERTIFICATES, LICENSES, REGISTRATIONS
Required:
RN,
CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA
Preferred:
BSN
PHYSICAL DEMANDS
Ability to lift 15-30lbs
Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters, or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews
WORK ENVIRONMENT
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
OTHER
Interaction with facility HIM and / or physician advisors
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
Compensation and Benefit Information Pay
Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience.
Management level positions may be eligible for sign-on and relocation bonuses.
Benefits Conifer offers the following benefits, subject to employment status:
Medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
401k with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.
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The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and 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 the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.
ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned.
Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.
Performs reviews of accounts denied for DRG validation and DRG downgrades.
Documents in 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 To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Effectively organizes work priorities
Demonstrates compliance with departmental safety and security policies and practices
Demonstrates critical thinking, analytical skills, and ability to resolve problems
Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
Possesses excellent written and verbal communication skills
Detail oriented and ability to work independently and in a team setting
Moderate skills in MS Excel and PowerPoint, 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
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE Education
Minimum Required:
Completion of BSN Degree Program or three years of experience and 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
Must have expertise with Interqual and/or MCG Disease Management Ideologies
Strong communication (verbal/written) 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, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS
CERTIFICATES, LICENSES, REGISTRATIONS
Required:
RN,
CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA
Preferred:
BSN
PHYSICAL DEMANDS
Ability to lift 15-30lbs
Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters, or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews
WORK ENVIRONMENT
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
OTHER
Interaction with facility HIM and / or physician advisors
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
Compensation and Benefit Information Pay
Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience.
Management level positions may be eligible for sign-on and relocation bonuses.
Benefits Conifer offers the following benefits, subject to employment status:
Medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
401k with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.
#J-18808-Ljbffr