Auditor RN

GENERAL SUMMARY:

Interprets and analyzes the patient's medical record to assure the patient's bill accurately reflects goods, supplies and services received. Responsible for reviewing all Medicare and other payers' outpatient bills to identify if specific services are diagnostic, therapeutic, or radiologic, to identify self-administered drugs, and to determine other specific regulation requirements. Works closely with patients, insurance companies, hospital departments, physician practices, and outside agency auditors to support hospital protocol, resolve/negotiate questioned charges, work with Revenue Integrity Liaisons and Reimbursement Specialists to write payer appeals when clinical expertise is needed and provider patient estimates.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Audits patient billings against the medical record following final billing; ensures compliance with third party payer requirements and departmental guidelines.

3. *Per audit criteria, reviews Medicare bills to determine if services require specific billing data according to Medicare regulations and provides the information necessary for claims processing.

4. *Maintains data on patterns of charge or documentation errors by department and charge item; works with the Revenue Integrity Team and departments on quality improvement processes when applicable.

5. *Performs internal audits as required by the Medical Center Internal Audit committee guidelines.

6. *Completes external audits and/or researches denied charges by outside audit agencies; works closely with external auditors to reconcile charges and, if needed, re-audit records; negotiates questioned charges, conducts exit interview and works with department directors to resolve discrepancies.

7. *Researches disallowed charges on cost outliers and submits to the Medicare reviewers appeal letters and any documentation verifying/supporting services provided.

8. Researches medical records for other billing process information as directed by the Patient Accounts Manager.

9. *Provides accurate price estimates to callers for requested procedures and tests either verbally or in written form; maintains the Price Estimate Caller database and logs all price estimate requests; synthesizes ongoing patient data for procedure averages based on diagnosis ICD-9 codes.

10. Identifies charges related to specific services for split billing based on third party payer coverage requirements.

11. *Collaborates with Risk Management, Quality Management, corporate compliance and departmental staff to resolve or initiate procedures/protocol changes to improve total quality as needed.

12. *Collaborates with Patient Accounts Staff, Patient Experience staff, and other department staff concerning patient questions or complaints on billing issues.

13. *Calculates observation visit charges on all outpatient status patients and confirms entries; communicates and verifies patient status with Care Management staff and bed control staff to prevent discrepancies and/or duplicate/missed charges.

14. Advances work knowledge by participating in continuing education inservices, reading periodicals/literature and seeking ongoing development opportunities.

15. *Maintains knowledge of all new patient service/equipment charges and charging methods; informs Patient Accounts Manager of new items being documented in the medical record that are not in the CDM (Charge Data Master).

16. Maintains awareness of financial reimbursement methodology, practices and regulations; participates in resource stewardship.

17. Attends staff meetings, mandatory inservices and other work-related meetings as appropriate.

18. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*").

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of medical documentation requirements.

2. Knowledge of patient medications, supplies and services provided within a healthcare environment.

3. Knowledge of clinical procedures performed in hospital ancillary, surgical and clinical departments.

4. Knowledge of nursing theory, practices/applications and new techniques.

5. Knowledge of billing, payer reimbursement policies, and diagnosis and procedural coding.

6. Knowledge of CMS, third party payer and Joint Commission regulations, quality improvement processes and corporate compliance plan.

7. Knowledge of computer hardware equipment and software applications relevant to work functions.

8. Knowledge of Charge Description Master and its relation to billing compliance and department revenue.

9. Knowledge of Microsoft Suite including word, excel, and power point.

10. Skill in constructive problem-solving and conflict resolution.

11. Ability to communicate effectively both verbally and in writing.

12. Ability to collaborate positively with co-workers and health care team members and to respond to patient/family needs with courtesy, consideration, tact and sensitivity.

13. Ability to evaluate documentations, interpret regulations and policies and make decisions in accordance with established precedent or protocols.

14. Ability to prioritize work demands and work with minimal supervision.

15. Ability to maintain confidentiality relevant to sensitive information.

16. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years clinical experience as a Registered Nurse required. Varied critical care and medical surgical experience preferred. Auditing experience preferred. Working knowledge of hospital charging, billing, and payer regulations.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.