Nurse Auditor
Lehigh Valley Health Network
full-time
Posted on:
Location Type: Remote
Location: Pennsylvania • United States
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About the role
- Functions as Hospital Liaison with Third Party billing and auditing firms for all audits for LVHN locations
- Reviews all audits in LVHN audit software and writes appeals for charge and line item audit denials as well as level of care and medical necessity denials
- Communicates audit results and develops action plan to reduce incidence of denials for LVHN
- Provides explanation of hospital charges to inquiring patients
- Participates in revenue recovery/revenue enhancement through the verification of correct charging procedures in EMR
- Provides education to hospital departments to facilitate correct charges on all claims
- Works with Physician Advisors on appeals to payors/third party vendor and documents their follow up in LVHN audit software and EMR
- Collaborates with management team to participate with Insurance providers and third-party audit vendors to resolve audit appeal disputes or issues
- Creates an audit appeal letter to uphold the claim based on our charging practices or medical necessity documentation found in the EMR or coordinates and implements on site audits as required in lieu of a written appeal
- Coordinates audit appeals that need a physician’s input with the payor and sends claims to write off that have no further appeals
- Coordinates downgrade of class as directed by Physician Advisor for audited claims
- Facilitates write off accounts that cannot provide support for line item denials or level of care denials
- Looks for missing charges and investigates charges and usage to be sure correct charges are on the claim
- Identifies areas of incorrect charging practice, provides action plan to correct charging and does follow up auditing for compliance of action plan
- Provides monthly reporting, while working with clinical data support team, for action plans, line item audits and medical necessity audits
- Keeps all assigned work ques current that includes but are not limited to Gift of Life, Life threatening, OBV hours, bed charges
- Ensures compliance with regulatory and accrediting requirements
- Charge corrections and conversion accounts will be worked by this group.
- Will complete special projects as assigned.
Requirements
- Specialized Diploma in nursing
- 10 years clinical experience
- Ability to read medical charts and identify deficiencies in documentation content
- Ability to adapt to ongoing changes within the health insurance industry
- Knowledge of medical policy per payor guidelines
- Knowledge of Auth/Cert and utilization review and hospital departmental procedures
- Knowledge of where to look for coding of claims and interact with HIM when needed
- Insurance knowledge of payor process and payment/audit rules
- Knowledge of Epic workflows with notes in account history and WQ Workflows
- Knowledge of hospital based charging methods such as charge tables, medical records and billing formats
- Intermediate knowledge of Excel and MS Word
- RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
Benefits
- Health insurance
- Paid time off
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical chart reviewcharge correctionsauditingappeals writingrevenue recoverymedical necessity documentationcoding of claimsutilization reviewhospital charging methodsExcel
Soft Skills
communicationcollaborationproblem-solvingadaptabilityeducationaction planningreportinginvestigationorganizational skillsinterpersonal skills
Certifications
Licensed Registered NurseSpecialized Diploma in nursing