Description

JOB SUMMARY

The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.Performs reviews of accounts denied for DRG validation and DRG downgrades.Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG’s, Outlier Payments, and Stop Loss calculations.Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

KNOWLEDGE, SKILLS, ABILITIES

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.

Effectively organizes work prioritiesDemonstrates compliance with departmental safety and security policies and practicesDemonstrates critical thinking, analytical skills, and ability to resolve problemsDemonstrates ability to handle multiple assignments and carry out work independently with minimal supervisionDemonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goalsPossesses excellent written and verbal communication skillsDetail oriented and ability to work independently and in a team settingModerate skills in MS Excel and PowerPoint, MS OfficeAbility to research difficult coding and documentation issues and follow through to resolutionAbility to work in a virtual setting under minimal supervisionAbility to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Includes minimum education, technical training, and/or experience required to perform the job.

Education

Minimum Required:Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employmentRN License in the State of PracticeCurrent working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.Preferred/Desired:Completion of BSN Degree Program CCDS certification or inpatient coding certification

Experience

Minimum Required:Three to Five years Clinical RN ExperienceThree to Five years of Clinical Documentation Integrity experienceMust have expertise with Interqual and/or MCG Disease Management IdeologiesStrong communication (verbal/written) and interpersonal skillsKnowledge of CMS regulationsKnowledge of inpatient coding guidelines1-2 years of current experience with reimbursement methodologiesPreferred/Desired:Experience preparing appeals for clinical denials related to DRG assignment.Strong understanding of rules and guidelines, including AHA’s Coding Clinics, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS

CERTIFICATES, LICENSES, REGISTRATIONS

Required: RN, CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMAPreferred: BSN

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to lift 15-30lbs Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters, or other designated sitesAbility to sit and work at a computer for a prolonged period of time conducting medical record quality reviews

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

OTHER

Interaction with facility HIM and / or physician advisors Must meet the requirements of the Conifer Telecommuting Policy and Procedure

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

Pay: $56,784.00 - $85,176.00 annually. Compensation depends on location, qualifications, and experience. Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

Conifer offers the following benefits, subject to employment status:

Medical, dental, vision, disability, life, and business travel insurancePaid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.401k with up to 6% employer match10 paid holidays per yearHealth savings accounts, healthcare & dependent flexible spending accountsEmployee Assistance program, Employee discount programVoluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.2503007934