[Hiring] RN Clinical Auditor @Ensemble Health Partners

Role Description

The RN Clinical Auditor performs complete government (MAC, CERT, RAC, OIG, ZPIC, UPIC, QIO, TPE, DRG), state (Medicaid, PERM) and commercial (Managed Medicare, Charge/Defense, Level of Care, Medical Necessity, Readmission) payer clinical audit reviews on assigned Clinical Audits, DRG Clinical Validation Audits, and clinically related claims as objectively and accurately as possible to uphold quality, compliance and performance standards across Ensemble Health Partners.

The Clinical Auditor RN assists with analyzing and reviewing clinical audit and DRG clinical validation audits to prevent future audits by providing clinical records to payers, contacting government and payer agencies, contacting physician offices, and preparing for physician advisor reviews.

Job Responsibilities:

• Review Clinical Audits:
  • Have in-depth knowledge of clinical nursing practices and clinical procedures.
  • Understand medical coding and billing (DRG, CPT, ICD-10) along with CMS rules and regulations.
  • Review medical records to ensure compliance with healthcare standards and regulations.
  • Validate accuracy and appropriateness of services given.
  • Record audit determinations using Ensemble Health Partners audit tracking system and document.
  • Prepare necessary materials for an audit response.
  • Collect all relevant patient medical records that are requested for the audit.
  • Ensure all documents are complete, accurate, and signed by appropriate healthcare providers.
  • Review documentation to ensure compliance with Medicare (or payer) requirements.
  • On bulk audits, promptly respond to any Notices of Review and requests for additional documentation.
• Data Analysis and Reporting:
  • Analyze medical records and data to identify trends and discrepancies.
  • Hold strong problem-solving skills to address governmental audit and compliance issues.
  • Keen eye for detail to ensure accuracy in audits and documentation.
  • Assist Clinical Audit Nurse Manager and Supervisor with detailed information on audit findings for reporting purposes.
• Collaboration and Education:
  • Work effectively with healthcare providers, management, and other departments.
  • Excellent verbal and written communication skills for reporting findings.
  • Ability to educate and train healthcare staff on best practices and regulations.
  • Participate and communicate during Governmental Audit Client Education Sessions.
  • Contact physicians, government auditors, commercial auditors, and insurance plans to determine reasons claims were denied.
  • Provide educational points and resources to healthcare staff on current best practices, policies, and regulations.
  • Attend one-on-one education sessions provided by the MAC to understand the audit findings and learn how to correct any identified issues.
• Guideline Development:
  • Understanding of healthcare regulations and standards (Medicare, Medicaid).
  • Participate in the development of clinical guidelines and protocols to ensure the highest quality of Clinical Audit reviews.
  • Assist with quality assurance functions such as development of auditing and educational guidelines as needed.
• Regulatory Compliance:
  • Stay updated with changes in healthcare regulations and standards, ensuring these changes are implemented in the healthcare facilities.

Qualifications

• 2+ years of regulatory audit experience, utilization review, clinical validation, denials or case management experience strongly preferred.
• Experience in hospital operations, chart audit/review, and clinical education.
• Ability to manage time, meet audit deadlines, and handle multiple tasks.
• Experience working in a production-based work environment.
• Flexibility to adapt to changing regulations, work multiple assigned audit tasks and healthcare environments.
• Ability to evaluate complex situations and make informed decisions.
• Familiarity with electronic medical records (EMR) systems.
• Experience using multiple software programs and tools.
• Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.

Requirements

• Associates or Bachelors Degree in Nursing.
• Registered Nurse (RN) license required.

Benefits

• Bonus Incentives.
• Paid Certifications.
• Tuition Reimbursement.
• Comprehensive Benefits.
• Career Advancement.