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Clinical Review Nurse Auditor (Remote must reside in TX)

Date:  Nov 17, 2022
Location: 

Dallas, TX, US

Category:  Corporate and Professional Jobs
Job Type:  Day
Requisition ID:  755521

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

 

Primary Purpose

Responsible for ensuring the integrity of the hospital's patient care/services billings and preventing revenue loss. Responsible for preparing, completing, and reporting data required to obtain appropriate reimbursement from payers. Responsible for compliance with governmental payer requirements through preparation of chart audit reports and process monitoring to reflect facility and department activities.

 

Minimum Specifications

 

Remote must reside in TX

 

Education

  • Completion of course work from an accredited college or university leading to an associate degree in nursing. A bachelor’s degree in nursing is highly desirable, or
  • Graduate of approved LVN program.

 

Experience

  • Must have six years of nursing experience, to include two years of auditing experience.
  • At least 2 years minimum experience in healthcare finance, or CDM/Revenue Integrity.

 

Equivalent Education and/or Experience

  • May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.

 

Certification/Registration/Licensure

  • Current, valid RN license or temporary RN license from the Texas Board of Nursing, or valid Compact RN license is preferred.
  • Must have current healthcare provider CPR course completion card from one of the following:
  • American Heart Association
  • American Red Cross
  • Military Training Network
  • Dual Hospital and Professional coding certification preferred (CPC, COC, CIC, CPMA)

 

Skills or Special Abilities

  • Must be familiar with the rules and regulations of the Texas Department of Insurance, Joint Commission, Workers' Compensation, Medicare, and Medicaid Ability to review, analyze, and interpret managed care contracts, billing guidelines, and state and federal regulations.
  • Must be able to understand and apply Current Procedural Terminology (CPT) and revenue codes to monitor proper usage and assure accurate billing procedures
  • Knowledge of treatment protocols, medical and surgical procedures, and other healthcare practices
  • Working knowledge of patient and financial accounting systems.
  • Must be able to work independently and communicate both orally and in writing with departmental personnel, hospital staff, vendors, insurance carriers, governmental agencies, and patients.
  • Well-developed research skills.
  • Must be able to demonstrate a working knowledge of PC-based word processing, spreadsheet, and data base software such as Excel and Word.
  • Must have effective oral and written communication skills, including advanced presentation skills.
  • Excellent organizational and project management skills to permit handling of large workload.
  • Background in managed care contract operations and /or billing compliance highly desired.

 

Responsibilities

  1. Responsible for promoting adherence to applicable State/Federal laws and regulations and the program requirements of accreditation agencies and Federal/State and private health plans in requests for third party reimbursement and charge audits. Research applicable laws, regulations and supporting documentation in the analysis of chargemaster, cost reporting, or other governmental and external reimbursement requests.
  2. Reduces risk to Parkland by identifying, documenting, and reporting potential compliance issues within their specific area of accountability, such as chargemaster coding reviews and billing compliance reviews. Audits established processes and procedures to detect errors or irregularities, assuring compliance with laws, regulations, and guidelines of Federal/State programs. Develops and implements new protocols and processes, programs, policies, and procedures specific to the auditing area that supports the standards, missions, goals, and objectives of Parkland.
  3. Coordinates data required for external audits, assuring timeliness and completion of projects. Documents and computes impact of possible compliance and billing issues according to department procedures.
  4. Identify opportunities and make recommendations for interdisciplinary and department process improvement such as analyzing Return to Providers (RTPs) or work queues. Lead department teams to implement changes, creating work plan and department procedures required.
  5. Works with all relevant hospital departments to provide timely education on improving deficient workflows in order to promote accurate billing and reimbursement. Prepares and conducts educational in-services related to accurate billing guidelines for IV administration and documentation. Works with physicians to ensure compliance with regulatory billing and documentation issues.
  6. Assesses, evaluates, and initiates necessary corrections pertaining to patient billing charges and documentation to ensure the integrity of the patient bill, prevent revenue loss, and provide nursing/billing information while ensuring the hospital’s mission of patient centered and patient valued care. Reconciles patient charges to documentation and provides rationale for appropriate charges and documentation to third party insurance payors, governmental agencies, Parkland’s leadership team and to patients/families.
  7. Analyzes billing errors and payer denials to identify root causes for correction and proper billing. This process will include a thorough review of the medical records and clinical documentation to verify services provided are accurately reported. Provide guidance, communication and ongoing education on correct charge capture and billing protocols to clinical departments as required.
  8. Serves as a liaison for internal and external customers by providing appropriate information and responses to defense audits, trends for risk management, lack of adherence to policies and procedures, responding to learning needs of auditors and patients/families billing concerns. Maintains a positive working relationship with all internal and external PHHS customers to assure that optimal and cooperation/customer satisfaction is achieved.
  9. Researches, identifies, and analyzes charge methodology, design of documentation, forms, billing and coding processes and procedures, workflows, trends, etc. for Parkland and implements or recommends appropriate changes to improve effectiveness, productivity, efficiency that support the overall goals of PHHS.
  10. Will work closely with the CDM team by being a liaison between all teams responsible for accurate billing and charge capture.

 

Job Accountabilities

  1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
  2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
  3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.

 

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.


Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth

Job Segment: Nursing, Registered Nurse, Patient Care, Healthcare Administration, Medicaid, Healthcare