ICU RN AUDITOR

Position Description.
Job Summary The ICU RN Auditor is responsible for rendering appropriate, well-supported, and thoroughly-documented decisions which may result in the identification of improper payments on paid claims to various providers of clinical services, including outpatient hospital, ambulatory surgical centers, Home Health and DME providers.
Job Responsibilities Your main responsibilities as ICU RN Auditor are as follows.
• The Clinical Nurse Auditor will be responsible for reviewing medical records to determine the medical appropriateness in a variety of care settings for clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients.
• The Clinical Nurse Auditor is charged with rendering independent, appropriate, well-supported, and thoroughly-documented decisions which may result in identification of improper payments on paid claims on behalf of the Client from various Providers of clinical services, including but not limited to acute care, outpatient and other Provider types and care settings.
• Conducts inpatient and outpatient claim audits to determine medical necessity/reasonable and necessary services, validation of prior authorization, clinical validation, medical service charge audit, or other audit types as required, thereby recovering improper payments when it is determined through the audit process that the medical record does not support the services billed.
Other types of audits may be performed as required by the Client.
• Develops rationale for the audit decision based on the provider's submitted information, citing appropriate review guidelines, applicable regulations and/or internal review guidelines, and enters clearly documented information in ProperPay.
Follows the designated procedure for referral to a Physician Advisor if required by Client contract.
• For Clinical Validation audits, documents specified coding issues in conjunction with the DRG Validation Team as assigned.
• Complies with department standards regarding productivity and audit quality.
• The Clinical Nurse Auditor reports to a Clinical Audit Team Leader, who provides support, feedback, and guidance to the Auditor.
Audit performance review, inter-rater reliability (IRR) and performance measurement (PM) are performed through a well-defined review and quality management program.
Qualifications.
• Must hold RN, LPN, CCS, CPC, RHIT, RHIA, or COC certification • USRN preferred but not required • Understanding of required field on ICD 9/10, CPT/HCPCS coding, DRG guidelines, correct coding initiative, revenue codes, modifiers and APC reimbursement • Minimum 5 years experience on Post Payment Claims Auditing and 5-10 years experience on ICU/CCU nursing experience • Strong understanding of third-party billing requirements to include Medicare/Medicaid and Commercial provider reimbursement methodologies • Post payment Claims Auditing experience of five years is a required • Intensive Care nursing experience of five or more years is required • In-depth knowledge of various diagnoses and clinical conditions, including complex and rare diseases, with a strong ability to assess the clinical validity of documentation.
• Expertise in identifying discrepancies between documented diagnoses and the clinical picture, ensuring that codes accurately reflect the patient's condition and care provided.
• Excellent written and verbal communication skills • Strong working knowledge of computer functions, Microsoft Office (Outlook, Word, Excel) applications, and Windows operating systems is required • Ability to coach, guide and review the case handled by colleagues.
• Team player, flexible, and can work well under pressure.
• Amenable to report to office per requirement.
Skills.
Analytical Thinking Data Analysis English What you can expect from us.
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