Intermountain Healthcare Nurse Auditor - Registered Nurse - Select Health in Murray, Utah
This position utilizes clinical expertise, expert coding knowledge and critical thinking skills to work collaboratively with SelectHealth's medical directors, internal and external compliance functions and healthcare provider partners to ensure medical necessity and accurate coding in compliance with NCQA's and other regulatory agencies' standards and turnaround requirements. This position also performs provider appeals process to research and notify of claims and coverage decisions made by SelectHealth's medical directors and compliance functions.
This position works with SelectHealth's Legal and Compliance Department, Health Services' Case Management, Utilization and Quality Department, and other Intermountain entities' physicians and staff to ensure compliance and appropriate payment of claims. Successful completion of these duties can impact SelectHealth's ability to maintain / obtain positive star ratings. CMS star ratings have a financial impact in the tens of millions range. Failure to comply with required regulations and appropriate claims payment put SelectHealth at risk for fines, penalties, NCQA accreditation and CMS star ratings.
Reviews and audits medical records in association with medical claims and provider appeals for appropriate CPT, ICD-9 (ICD-10) coding and for medical necessity utilizing clinical expertise, assessment of patient and medical documentation and coding knowledge and skills.
Utilize critical thinking skills to conduct regulatory comparison with submitted claims and coding with Centers for Medicare and Medicaid (CMS), Current Procedural Terminology (CPT), National Correct Coding Initiative (NCCI), Medicaid state requirements and National Committee for Quality Assurance (NCQA).
Ensure claims are reviewed and released within ERISA (Employee Retirement Income Security Act) standards for turnaround time.
Analyzes provider appeals for trends in inappropriate coding, fraudulent billing patterns, and opportunities for physician education. Reports and coordinates with other departments for appropriate action and educates providers on incorrect use of codes and support them in correcting documentation and billing inaccuracies.
Consults with physicians and providers offices on coding denials, edits and reviews. Coaches physicians and office staff on policies and processes to avoid future denials.
Facilitates review and creation of medical, coding and reimbursement policies for consistent and appropriate review of submitted claims, appeals and medical records.
Monitors, maintains, and initiates changes in system set up to maintain compliance with coding regulations and edits.
Administer plans consistent with benefits and Certificates of Coverage filed through State Departments of Insurance.
Maintains current critical knowledge of coding required to administer auditing functions.
Gains and maintains knowledge on current/future national, regional and local healthcare coding regulations. Train and mentor new or existing staff. Provides external provider training on coding regulations and billing practices.
Demonstrates a comprehensive understanding of SelectHealth?s internal processes and procedures.
Demonstrates excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physician, office staff and other external and internal customers and departments.
Bachelor's degree in Nursing (BSN) from an accredited institution. Intermountain verifies both degree attainment and educational institution accreditation following an offer of employment.
Currently licensed as a Registered Nurse (RN) in the State of Utah.
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Current coding certification from a nationally recognized organization (e.g. American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)) or will receive within 1 year of hire.
Five years of clinical experience
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Experience on word processing, internet searches and spreadsheets.
Three years of health insurance experience.
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Experience in training and auditing procedures.
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Clear understanding of health care products.
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Demonstrated teaching and leadership ability.
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Ability to communicate successfully, professionally and effectively with all individuals, professional and private, in writing and verbally.
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Ability to establish and maintain rapport with co-workers, physicians, other health care providers and clients.
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A working knowledge of managed care, ICD-9/CPT 4 coding, length of stay guidelines, and appropriate levels of care and modalities by diagnosis/procedure in multiple clinical areas.
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Able to work independently, and be self-motivated with a positive attitude and flexibility in a rapidly changing environment.
Ongoing need for employee to see and read information, assess member needs, and view computer monitors.
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Frequent interactions with providers, members that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues accurately
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Manual dexterity of hands and fingers, this includes frequent computer use and typing for documenting member care, accessing needed information, etc.
SelectHealth - Murray
Scheduled Weekly Hours:
Being a part of Intermountain Healthcare means joining a world-class team of over 38,000 employees and caregivers while embarking on a career filled with opportunities, strength, innovation, and fulfillment. Our mission is: Helping people live the healthiest lives possible.
Our patients deserve the best in healthcare, and we deliver.
To find out more about us, head to our career site here .
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Equal Opportunity Employer
Intermountain Healthcare is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor.
All positions subject to close without notice. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability or protected veteran status. Women, minorities, individuals with disabilities, and veterans are encouraged to apply.
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