Revenue Integrity Nurse Auditor
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GENERAL SUMMARY
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ESSENTIAL DUTIES AND RESPONSIBILITIES
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Ensures adherence to regulatory requirements related to billing and supporting documentation, as well as facilitates the completion of appeals in a timely manner.
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Prepares trend and other reports for compliance audits and charge processes.
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Serves as a resource to hospital departments regarding compliance with billing regulations and trends in denials of services due to medical necessity or appropriateness of services.
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Conducts compliance, defense, LifeNet and special focus audits and reports findings.
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Serves as a clinical resource for coding / denial management and customer service issues.
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Participates as a member of the chargemaster team, providing clinical support and expertise on compliance related charge functioning.
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Identifies and works collaboratively to correct discrepancies in patient charges.
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Performs other duties as assigned.
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LICENSES AND/OR CERTIFICATIONS
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Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license.
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Certified Professional Coder required.
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Certified Outpatient Coder (COC; formerly CPC-H) required within 1 year of hire.
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MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
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Graduate of a Bachelors of Science in Nursing program required.
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Minimum of 3 years of clinical experience as a Certified Professional Coder required.
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Three to five years of case management utilization review, or compliance related work experience in a hospital setting preferred.
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Pediatric experience preferred.
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Current knowledge of third party billing, appeals, regulatory and accrediting requirements required.
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Exceptional analytical skills necessary to determine appropriateness of patient charges in relation to medical records and third party reimbursement.
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Interpersonal skills necessary in order to communicate effectively with other professionals.
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Demonstrates proficiency in MS Office and other health record management systems.
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Knowledge of quality management methodologies, medical record documentation, compliance requirements and performance improvement system.
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Demonstrates the ability to prepare reports and summaries.
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WORKING CONDITIONS
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PHYSICAL REQUIREMENTS
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