Job Summary:
Responsible for day-to-day review, coordination and management of Clinical denials requiring background and understanding from a provider operational and payer logistical perspective. Auditor must work with a diverse group of other health care professionals to conduct review and appeal of Clinical denials related to all Payor plans. Represents Avanti Hospitals from a system perspective when working with payers to challenge and overturn denials of Clinical nature. Manages overturn rate data and evaluates trends for improvement opportunities. Works as part of the team to develop meaningful information for Hospitals and other stakeholders to improve operational performance and cash collections. Nurse auditor must have knowledge of government/State policies. The auditor should have strong project management and analytical skills and be able to handle projects simultaneously. Auditor should be able to work well individually or as part of a team. Assists with chart and Defense audits with outside payors. Assist with CDM charge and coding reviews.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
Essential Functions:
- Evaluates all Clinical denials for possible overturn opportunity. Prepares Appeals as required. Works closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts.
- Works as part of a team to develop and administer all Clinical denial workflow and processes.
- Works closely with Case Managers and Collection Manager to review cases and provide guidance in understanding the interplay between clinical and technical denials.
- Tracks and manages denied accounts, including triaging denials with the Case Managers and Collections Manager to quickly and expeditiously evaluate collectability.
- Based on initial review of accounts, manages various “buckets” of issues across hospitals to resolution.
- Identifies and escalates consistent issues and trends with payers to support leadership when meeting with payers to resolve issues.
- Provides fact-based information to Leadership on a regular basis on clinical denial performance with recommendations on process improvements to avoid denials in the future.
- Complies with Federal, State, and Local Laws that govern business practices.
- Understands and abides by all departmental policies and procedures as well as the Code of Ethics, HIPAA requirements and patient rights.
- Performs other job-related tasks, and special projects as assigned.
- Assists with chart and Defense audits with outside payors.
- Assist with CDM charge and coding reviews.
- Assists with disputes and reviews and discusses with patients.
- Documents findings in financial systems and in report excel format.
- Works correspondence pertaining to clinical denials.
- Communicates with Billing and Collections departments, and other Revenue Cycle departments.
- Creatively applies job knowledge and experience to solve difficult problems and regularly provides suggestions for quality improvement.
- Works with Leadership to recommend ways to maximize the use of the department to support strategic and operational needs of the Hospital.
Behavioral Standards:
- Exhibits customer and service-oriented behaviors in everyday work interactions.
- Demonstrates a courteous and respectful attitude to internal workforce and external customers.
- Communicates accurately and appropriately.
- Works well and efficiently under minimal supervision.
- Handles difficult situations in a discreet and professional manner.
- Is adaptable to changes in assignments and priorities.
Communication/Knowledge:
- Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.
- Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
- Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
- Able to use IT systems in an accurate and proficient manner.
Collaboration/Teamwork:
- Contributes toward effective, positive working relationships with internal and external colleagues.
- Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.
Qualifications/Experience:
- Computers skills, preferred.
- At least two (2) to three (3) years of current experience in an acute care hospital setting. preferred.
- Excel knowledge, required.
Licenses & Certifications
Required
- RN Registered Nurse
Preferred
- MAB AB508 Mgt Assaul Behv
- LVN Licn Vocational Nurse