Summary

With direction from the Patient Financial Services Director, the Nurse Auditor/ Revenue Integrity/ CDM Analyst is responsible for performing audits of 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/ CDM Analyst works directly with revenue producing departments regarding lost charges, billing questions, proper coding and charging, education on appropriate charge capture and providing CDM support, research and maintenance of the Charge Description Master.  The nurse auditor/CDM analyst reviews documentation on all Observation accounts for carve-out observation hours, extended recovery, 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 Collaborate 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 Works with the revenue producing departments to ensure the ongoing coordinated and consistency with the Chargemaster and Charge Capture processes, including accurate descriptions, coding, additions, deletions, pricing, revenue code and any other changes. Assists as needed, with data entry, billing/audit questions, facility inquiries, education, database maintenance, statistical analysis and processing of reviews of internal audits. Work with Finance and Revenue Integrity Committee to perform applicable analyses to understand budget, net revenue change and labor impact of proposed Charge master changes Maintain a working knowledge of revenue cycle process to aid in the implementation of regulatory standards that assist the health system in cash collection while accurately complying with billing guidelines Advises and collaborates with Internal Audit, Regulatory Review and Analysis, and outside consultants to analyze, review and assess identified billing, coding, charging and compliance issues Understands and reviews payer remittance advises, remit/remark code reason codes and how the codes translate into denials table. Understands denials prevention, root cause and works effectively to identify trends Serves as internal resource and expert on CDM issues and reporting Perform other related duties incidental to the work described herein Oversees the overall maintenance and use of the charge master tool utilized by the Revenue Management Department Performs analysis, identifies trends, validation of compliance as related to fiscal activities generating additional revenue, reducing bad debt expense and charity write-offs and overall expense reduction Performs analysis, identifies trends, validation of denials data and review of root cause analysis to help identify trends and activities generating additional revenue, reducing provider liable write offs and overall net revenue loss. Performs analysis, provides forecasting of net payments Disseminate CMS updates to health care providers as they relate to billing for drugs, implantable and/or other pass-through eligible items, ensuring the necessary changes are made to the entity specific Chargemaster and Charge capture updates within the time frame for accurate and compliant billing. Responsible for revenue code and coding assignment for all new items or services throughout CRMC Recommend policies and procedures which impacts charge capture and pricing practices Responsible for the supervision and coordination of Chargemaster and Charge Capture process in researching coding and billing guidelines, researching insurance contracts, and updating hospital and professional Chargemaster and Charge Capture processes. Represents CRMC with external vendors (e.g., EPIC)

 

 

 

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 or university, Certified Revenue Integrity 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 and or RHIA with CCS Certified Coding Specialist and CRIP