$150K — $200K *
The Sr Nurse Auditor is responsible for overseeing the auditing of patient bills against the medical records, determining accuracy, making changes, as necessary, and providing corrective intervention to reduce further occurrences. They shall demonstrate thorough knowledge and experience in managed care, utilization management, discharge planning and continuous quality improvement and integrate these concepts into the provision of auditing the financial and medical records for pediatric patients of varying ages and developmental levels. The Sr Nurse Auditor shall develop and maintain the medical auditing policy and procedure manual for RCHSD’s medical auditing practices, supervise and conduct performance appraisals of those staff assigned to perform medical auditing responsibilities, and develop productivity, quality control and process improvement measures that govern the medical auditing responsibilities. The Sr Nurse Auditor performs reviews of the medical and financial records and communicates with members of the financial services, health information and clinical service teams and other healthcare individuals, as part of the auditing process. The Sr Nurse Auditor will liaison with Health Information, Patient Accounts, Clinical Service Departments, Risk Management, Corporate Compliance and Commercial Insurance companies too ensure accurate and compliant charge capture processes and outcomes, conducting defense audit processes when necessary. They will assist coders with clarification of medical necessity for specifics and accuracy of coding. The Sr Nurse Auditor will conduct ongoing clinical service departmental training and education materials. They will track and trend medical auditing results, performing quantitative and qualitative analysis, as necessary, to propose performance and/or quality improvement measures. The Sr Nurse Auditor will report to Corporate Compliance, Risk Management and Quality Assurance, any identified and potential quality of care/service, liability/risk management or non-compliant billing issues.
- Bachelor's Degree
- 10+ years of experience, with minimum of 2 years recent hospital/clinical experience.
- California RN License
- Business experience with proven analytic and decision making skills.
- Working knowledge of Microsoft Office applications, including Microsoft Excel, and demonstrated ability to work in a variety of software applications and systems.
- Knowledge of authorization protocols for commercial insurance plans, state and federal health coverage plans, including California Children's Services and Medi-Cal programs and regulations.
- Working knowledge of payor reimbursement guidelines, contract reimbursement, health information management, JCAHO standards, and other regulatory requirements.
- Applied knowledge of ICD9-CM, CPT and HCPCS codes pertaining to billing regulations and requirements.
- Working knowledge of Utilization Management Protocols (aka Interqual, Milliman).
- Certified Professional Coder
- Working knowledge of Utilization Management Industry Standard Protocols (aka Interqual, Milliman).
- Utilization Management, Quality Management, or Case Management experience in an HMO Setting
Valid through: 11/24/2020