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MO-REMOTE
Worker Type:
Regular
Job Summary:
Ensures the daily management of auditing, monitoring of processes, reporting, and outcomes to ensure Care Transformation is compliant with regulatory requirements and standards are maintained. Performs clinical audits within Care Transformation operations by supporting the Clinical Documentation Improvement, Utilization Management, Status Review, and Case Management departments. Performs operational audits and compliance audits adhering to regulatory requirements. Standardizes policies, procedures and reporting for all auditing procedures.
Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES

• Creates and maintains auditing tools, procedures, and reporting for all areas of Care Transformation operations: Clinical Documentation Improvement; Utilization Management and Status Review; Case Management Standard Work.
• Performs operational and compliance audits adhering to regulatory requirements.
• Creates and standardizes policies, procedures and reporting for all auditing procedures.
• Reviews patient medical record documentation related to Clinical Documentation Improvement, Utilization Management and compares against medical bills, claims and revenue reports.
• Participates in training of specific area of focus by tailoring to specific needs identified within auditing findings.
• Utilizes auditing data, along with data analysts/liaisons, to improve risk adjustment measures and denial management processes within department.
• Resolves inquiries from internal and external sources to reconcile accounts accurately and within compliance guidelines.
• Ensures compliance with government and billing guidelines by reviewing and splitting or combining claims per clinical/billing guidelines. Enhances net revenue by splitting charges that should be presented on separate claims to capture entitled revenue.
• Improves claim submissions by reviewing, researching, resolving, and trending claim issues in a timely manner.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• 7 year’s relevant experience in clinical auditing

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

State of Work Location: Illinois

• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location: Oklahoma

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location: Wisconsin

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:
Day Shift (United States of America)
Employee
Department:
8764070033 System Care Coordination
Scheduled Weekly Hours:
40
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status , or any other characteristic protected by applicable law. Click here to learn more.