Full-Time
Nurse Auditor
Direct Staffing
No salary listed
Salt Lake City, UT, USA + 6 more
More locations: Seattle, WA, USA | Tacoma, WA, USA | Medford, OR, USA | Burlington, WA, USA | Moscow, ID, USA | Portland, OR, USA
In Person
Must work in office at least 6 months before telecommute eligibility.
Category
 Medical, Clinical & Veterinary (2) |
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Required Skills
Excel/Numbers/Sheets
Requirements
- The candidate must have an Associate or Bachelor’s Degree in Nursing or a related field and at least five years of hospital quality management, coding, or medical auditing experience, or an equivalent combination of education and experience.
- A currently unrestricted Registered Nurse license is required for medical care management.
- Proven knowledge of medical and surgical procedures and other healthcare practices and trends.
- General computer skills including Microsoft Office, specifically Excel and Outlook, and internet search.
- Familiarity with health care documentation systems.
- Strong verbal, written and interpersonal communication and customer service skills.
- Ability to communicate audit outcomes and testing results with staff within the company who are both medically and non-medically oriented.
- Ability to interpret policies and procedures and communicate complex topics to others.
- Strong organizational and time management skills with the ability to manage workload independently.
- Ability to think critically and make decisions within the role and responsibility.
- Proven ability in developing and following an audit program.
- Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).
Responsibilities
- Plan, coordinate, conduct and report on post payment claims audits and perform related special projects as assigned.
- Conduct coding audits, quality assurance assessments of claims, reviews statistical samples and analyzes for risk.
- Conduct surveys of complex audit areas to define the scope and objectives of audits.
- Assist in the development of overall audit plans, including comprehensive audit programs that identify specific procedures and tests designed to achieve the audit objectives.
- Identify problems or needed changes, recommend resolution, and participate in quality improvement efforts.
- Respond in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
- Provide consistent and accurate documentation.
- Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals.
- Understands and analyzes complex provider and hospital contracts in order to ensure payments are for covered services.
- Applies clinical expertise and judgment to ensure payments comply with medical policy, medical necessity guidelines, and accepted standards of care.
- Uses evidence-based criteria that incorporates current and validated clinical research findings.
- Practices within the scope of their license.
Desired Qualifications
- Certified Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred.
- Ideal candidate with experience in Skilled Nursing Facilities or a varied clinical setting with chart auditing experience strongly preferred.
- Experience with working for another health insurance plan is preferred.