Nurse Auditor/Revenue Integrity (FLEXI)

Summary

With direction from the Director, the Nurse Auditor/ Senior Revenue Integrity Specialist is responsible for auditing itemized charges versus the patient medical record and other applicable hospital documentation, assigning modifiers to appropriate claims, researching edited claims for medical necessity, and advising the billing staff of appropriate HCPCS codes and modifiers. The Nurse Auditor/ Revenue Integrity Specialist works directly with revenue producing departments regarding lost charges, billing questions, and proper coding and charging. The nurse auditor reviews documentation on all Observation accounts for carve-out observation hours, the charge coding of ED Visits and Injection and Infusion charges.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Coordinate, supervise, and respond to third party patient bill audits. Perform patient requested audits in a timely manner. Perform random quality audits as schedule permits.

• Work and review a high volume of accounts assigned to Revenue Integrity Nurse Auditor work queues for charge review of all observation account documentation to charges, carve-out observation time from procedures, review documentation to charge code injection and infusion charges and the review of ED documentation to assign and charge code appropriate visit levels to ED visits.

• Assist Patient Account personnel with patient questions about itemized charges.

• Maintain reporting system of audit activities and identifies pattern and trending of results.

• Act as resource for all hospital departments with charging questions and issues.

• Routinely review and analysis of inpatient and outpatient records for appropriate coding and charging.

• Provide educational sessions for revenue producing departments regarding appropriate charging process and procedures.

• Work cooperatively with the Patient Accounting staff and other health care professionals in obtaining correct HCPCS codes and modifiers.

• Assist the Health Information Department with RAC requests, coding reviews, and denials.

• Ensure accuracy and integrity of charge data prior to billing interface and claims submission.

• Utilize a computerized encoding system to facilitate accurate coding; and sequence diagnoses and procedures by following the ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.

• Report trends and improvements to the Director of Patient Accounts regarding assigned HCPC codes and modifiers.

• Receive, review, verify, and process requests for chart audits of inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews from finance and/or claims department.

• Prepare written reports for finance and claims departments including explanations for recovery of money and appropriate regulatory agencies.

• Educates provider services, claims, recovery, finance and other department staff on the outcomes of the audit results and assists provider services with educational efforts.

• Provide feedback and process improvement recommendations to appropriate hospital departments and committees based on analysis and trending of hospital or provider audits.

• Provide written explanations to patients who are questioning their bills. Must be able to communicate effectively verbally and in written format to clinical and non-clinical staff and individuals.

• Familiar with coding diagnostic and procedural information from the record using ICD-10-CM and CPT-4/HCPCS classification systems. Utilize a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.

• Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate.

• Attend hospital-wide orientation, in-services, educational meetings, and other meetings as required.

• Attend other continuing education functions as necessary to maintain credentials, regardless of whether the educational programs are supported by the Department budget.

• Exhibit excellent customer relations to patients, visitors, physicians, and co-workers.

• Show courtesy, compassion, honesty, and respect to others in the adherence to the Hospital's mission, philosophy, and policy for promoting a positive work and customer environment.

• Adhere to CRH's confidentiality policy for all information related to patients, family and friends, hospital employees, physicians and clients.

• Maintains effective interdepartmental communication.

• Adhere to CRHs confidentiality policy for all information related to patients, family and friends, hospital employees, physicians and clients.

• Maintain effective interdepartmental communication.

• Attend required hospital-wide orientations, meetings, and in-services.

• Demonstrate a commitment to flexible work scheduling when necessary.

Supervisory Responsibilities

Reports to: Director, Patient Accounts
Supervises: None
Responsibilities: Not applicable

Qualifications

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.

Education and Experience

Minimum Required Education:

Graduate of an approved school of professional

Preferred Education:

Bachelor of Science in Nursing preferred

Experience:
Senior Level Coding experience of at least 20 years or 10 years in a coding management level recent experience coding in an acute hospital setting required, with coding ability demonstrated via a skills assessment or a RN with 20 years of experience as an intensive care unit, emergency department or documentation specialist nurse auditor or an LPN with a combined coding and auditing background. Experience with health information systems and computer technology required. Ability to communicate effectively, both verbally and written format. Must be able to work independently with attention to detail and accuracy.

Certificates, Licenses, Registrations

Current Virginia Nursing License.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

• Continuous Learning

• Job Knowledge

• Use of Technology

• Problem Solving

• Customer Service

• Communications

• Cooperation

• Oral Communication

• Teamwork

• Quality Management

• Conflict Resolution

• Cost Consciousness

• Diversity

• Ethics

• Organizational Support

• Adaptability

• Achievement Focus

• Personal Appearance

• Attendance/Punctuality

• Dependability

• Initiative

• Innovation

• Judgment

• Planning/Organizing

• Quality

• Quantity

• Safety and Security