Job Summary

With direction from the Director, the Nurse Auditor/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.

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

·       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 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 CRMC's confidentiality policy for all information related to patients, family and friends, hospital employees, physicians and clients

·         Maintains effective interdepartmental communication

·         Adhere to CRMCs 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

Education and Experience

Minimum Required Education: Graduate of an approved school of professional Nursing.  Preferred Education: Bachelor of Science in Nursing preferred

Experience: Senior Level Coding experience of at least five years recent experience coding in an acute hospital setting required, with coding ability demonstrated via a skills assessment or five years of experience as an intensive care unit , emergency department or documentation specialist nurse auditor. 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 RN License.