The Opportunity:

CAREER OPPORTUNITY OFFERING:

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• This position pays between $63,100.00 - $108,900.00 based on experience

The RN Clinical Auditor performs complete government (MAC, CERT, RAC, OIG, ZPIC, UPIC, QIO, TPE, DRG), state (Medicaid, PERM) and commercial (Managed Medicare, Charge/Defense, Level of Care, Medical Necessity, Readmission) payer clinical audit reviews on assigned Clinical Audits, DRG Clinical Validation Audits, and clinically related claims as objectively and accurately as possible to uphold quality, compliance and performance standards across Ensemble Health Partners. The Clinical Auditor RN assists with analyzing and reviewing clinical audit and DRG clinical validation audits to prevent future audits by providing clinical records to payers, contacting government and payer agencies, contacting physician offices, and preparing for physician advisor reviews.

Job duties include but are not limited to contacting regulatory bodies such as MACs (Medicare Administrative Contractors) and payers to determine the reason for the audit, reviewing audit letters, analyzing claims, reviewing for compliance rules and regulations, gathering appropriate medical records from client EMR per government requirements, determining if an audit is necessary, preparing the audit materials. The Clinical Auditor RN will work in tandem with Ensemble/Client compliance educate other departments (PA, HIM, case management, client departments, revenue integrity, coding, CDI, etc.) on any audit outcomes and assist in developing action plans for prevention. The primary goal of the RN Clinical Auditor is to ensure the delivery of high-quality, cost-effective reviews and to minimize financial risk to Ensemble Health Partners and clients. This role involves a combination of clinical expertise, data analysis, exceptional communication abilities, and regulatory/compliance knowledge to maintain and improve healthcare standards.

Job Responsibilities:

Review Clinical Audits:

• Have in-depth knowledge of clinical nursing practices and clinical procedures. And an understanding of medical coding and billing (DRG, CPT, ICD-10) along with an understanding of CMS rules and regulations concerning governmental audits including knowledge of CMS polices, Local Coverage Determinations, National Coverage Determinations, and Billing Articles and ability to review within electronic medical records.
  • Review medical records to ensure compliance with healthcare standards and regulations
  • Validate accuracy and appropriateness of services given
  • Record audit determinations using Ensemble Health Partners audit tracking system and document
  • Preparing the necessary materials for an audit response.
  • Collecting all relevant patient medical records that are requested for the audit
  • Make sure all documents are complete, accurate, and signed by the appropriate healthcare providers
  • Review the documentation to ensure it complies with Medicare (or payer) requirements.
  • On bulk audits, such a TPE and cost outlier, promptly respond to any Notices of Review and requests for additional documentation
  • Other tasks mentioned in the job summary.

Data Analysis and Reporting:

• Analyze medical records and data to identify trends and discrepancies. Hold strong problem-solving skills to address governmental audit and compliance issues. Keen eye for detail to ensure accuracy in audits and documentation. Thoroughness in reviewing patient charts and medical records.
  • Analyze data to identify trends, discrepancies, and areas needing improvement.
  • Assist Clinical Audit Nurse Manager and Supervisor with detailed information on audit findings for reporting purposes

Collaboration and Education:

• Work effectively with healthcare providers, management, and other departments. And strong interpersonal skills to facilitate teamwork and cooperation. Excellent verbal and written communication skills for reporting findings. Ability to educate and train healthcare staff on best practices and regulations. Participate and communicate during Governmental Audit Client Education Sessions

• Work closely with other healthcare professionals to implement changes and improvements based on audit findings.
• Contact physicians, government auditors, commercial auditors and insurance plans to determine reasons claims were denied
• Provide educational points and resources to healthcare staff on current best practices, policies, and regulations.
• Attend one-on-one education sessions provided by the MAC to understand the audit findings and learn how to correct any identified issues. Provide feedback to client and Ensemble departments (coding, CDI, and RI) and assist in developing action plans

Guideline Development:

• Understanding of healthcare regulations and standards (Medicare, Medicaid). And stay updated with changes in healthcare laws and guidelines
  • Participate in the development of clinical guidelines and protocols to ensure the highest quality of Clinical Audit reviews, and prevention of Clinical Audit audits.
  • Assist with quality assurance functions such as development of auditing and educational guidelines as needed

Regulatory Compliance:

• Stay updated with changes in healthcare regulations and standards, ensuring these changes are implemented in the healthcare facilities

Experience We Love:

• 2+ years of regulatory audit experience, utilization review, clinical validation, denials or case management experience strongly preferred
• Experience in hospital operations, chart audit/review, and clinical education
• Ability to manage time, meet audit deadlines, and handle multiple tasks.
• Experience working in a production-based work environment
• Flexibility to adapt to changing regulations, work multiple assigned audit tasks and healthcare environments. Ability to work independently and manage workload.
• Ability to evaluate complex situations and make informed decisions.
• Familiarity with electronic medical records (EMR) systems.
• Experience using multiple software programs and tools.
• Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.
• This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.

Minimum Education:

• Associates or Bachelors Degree in Nursing

Required License:

• Registered Nurse (RN)

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