Reporting to the Audit and Appeals Supervisor, the Audit and Appeals Nurse plays an important role in a high-profile group tasked with audits and appeals for all government and commercial payers due to Audit request and denials. The focus is to improve revenue results by taking a global view of clinical and financial processes, functions and interdependencies from the provision of patient care to the final bill generation. Due to its service focus and project management emphasis, this position requires strong interpersonal and communication skills, well-developed analytic and organizational skills, and the ability to meet deadlines while influencing, but not directly managing the work of others.

Your Everyday

GENERAL DUTIES

• Manage payer denials by conducting retrospective comprehensive analytical review of clinical documentation to determine if an appeal is warranted in a timely manner
• Exercise discretion and independent judgement when completing medical record quality audits of clinical validation documentation and work prepare appeal arguments in conjunction with the appropriate department as it relates to payer policy/procedure, contract agreement and regulatory requirements.
• Research and analyze the RRL (review result letters) for government and third-party payer denials related to DRG Assignment, Medical Necessity, Level of Care, and Clinical Authorizations to send to the appropriate department; provides supporting documentation for audit and appeal in order to pursue resolution through all appeal levels, according to relevant government and third-party payer guidelines; monitor pre-billing and post billing to assist in ensuring accurate reimbursement by identifying opportunities prior to bill submission and correcting problems once the medical record has been completed.
• Follow up communication with physicians and other provider personnel to ensure documentation available supports submitted charges. Work with the Audit and Appeals coordinator to complete the appeals process.
• Collaborate with Compliance, Case Management, Coding, Patient Access, Managed Care Contracting, Central Business Office, Health Information Management, Finance, and Clinical departments to resolve Audit and Appeal trends and or other issues as identified. This includes projects related to revenue cycle initiatives.