Join our Talent Network

Audit Appeals Nurse (Case Manager, Utilization Review)

Job ID: 745
Facility:
City: Greensboro

Share:

Job Description

40 hours/week (Exempt)
8 hour days
8 am to 5 pm

EDUCATION:
Required:
Associates - Nursing OR Associates Degree--Registered Health Information Administrator (RHIA)

Preferred:
Bachelors - Nursing

Additional Information
Graduate of a School of Nursing. BSN required or with approval of the hiring manager, experienced RN's with an AD or Diploma with an active plan to
obtain their BSN within four years from date of hire may be considered.

LICENSURE/CERTIFICATION REGULATORY:

Required:
RN--Registered Nurse licensed in North Carolina or a Compact state or RHIA

JOB SUMMARY:
The Government Audit Coordinator will oversee the Government Audit implementation and response team. Develop workflows, policies and procedures and the communication plan to prepare for audit requests, denials and appeals in accordance with our compliance plan. Evaluates and reports risk and develops workflow redesign if necessary.

MAJOR WORK ACTIVITIES:
Audit Request: Manages all requests received from government audit Payor/contractor. Ensure chart documentation has been reviewed before mailing to include cover letter pointing out medical necessity and admission screening documentation. Maintains copies of all documentation sent. Ensures documentation is mailed within the time frame. No exceptions. 20%

Appeals: Administers the appeal and denial process. Follows appeal and denial process through the entire 5 Levels of appeal until a resolution is made .Documents the outcome of each level of appeal. Completes workque in EPIC/electronic medical record to ensure accounts continue to process appropriately 20%

Documentation: Ensures required information is documented into the tracking system upon receipt of denial or request from Payor/Contractor. Identifying reason for denial or request and updates system until resolution is complete. Maintaining 100% accuracy. Collect, organize and interpret data for identification and prioritization of areas of risk. Maintaining and submitting reports timely. Performs concurrent documentation reviews of selected records to clarify conditions/diagnoses and procedures. Recognizing the need for additional documentation or clarification and secures the documentation from the appropriate person. Displays extensive knowledge of documentation standards required by licensing/regulatory agencies and documentation standards/guidelines relating to coding/billing. 20%

Reviews/Policy: Develops changes t
rganizational practice, policies and procedures as needed in response to audit issues. Coordinates reviews for audit testing to ensure established regulations and policies are met. Monitors and identify potential issues. Complies reports as a result of reviews. Remains current through education and participation with various organizations. 20%

Reporting: Reports to Compliance Officer and/or Administration information such as the likelihood of denial; dollar amount of account; any identified documentation issues and reports progress. Works with Revenue Cycle, HIM, Compliance, CFO and Legal Counsel on guidelines to follow audit responses and to ensure smooth workflow. 20%

WORKING CONDITIONS:
Occurs under one-third of the time:
• Exposure to bloodborne pathogens
• Hazardous waste and/or toxic / caustic chemicals
• Fumes or airborne particles
Additional information on Working Conditions:
Sufficient mobility to travel within and between health system facilities. Ability to visualize the computer monitor and use automated communication devices such as fax, voicemail and email.

iCARE - COMMITMENTS TO CARE:

Communication
I will create and engage in conversations of possibility.
I will be open to innovation and creativity.
I will listen to understand.
I will bring ideas for solutions and be open to alternative ideas.
I will be open to constructive feedback.
I will not engage or listen to negativity or gossip.
I will be positive when speaking about Cone Health, my department, and my coworkers.
I will be approachable.
I will focus on behaviors, not the person, during conflict.

Accountability I will honor my word.
I will do what I say when I say I will.
I will "clean it up" when I can't keep my word.

I will honormy work agreement.
I will be "on the court" instead of "in the stands."
I will follow up in a timely manner on commitments and requests.
I will apologize when someone experiences less than excellent service.
I will take responsibility for my actions, decisions and performance.
I will protect patient safety (best practices: ex - hand hygiene).

Respect
I will assume the best of intentions and embrace differences.
I will collaborate and seek other people's input.
I will demonstrate courtesy, compassion, and respect with my tone of voice and body language.
I will speak positively about Cone Health - managing up coworkers, physicians, departments, patients and visitors.
I will ask the person directly involved when I don't know.
I will include diverse skills, abilities, strengths, and backgrounds to create better outcomes.
I will care for myself while also respecting others.

Empowerment
I will own it, solve it, and celebrate it!
I will offer solutions when problems are identified.
I will share my input for decisions by participating in forums such as shared governance, town halls, employee engagement survey, brown bag discussions, employee councils, staff meetings, or directly with my manager.
I will take charge and do the right thing at the right time.
I will make decisions keeping a balance of service, quality, and cost in mind.
I will demonstrate Cone Health values.
I will seek opportunities to celebrate and have fun.
I will recognize good work.

I have seen and reviewed the job description in its completed form and understand that I will be required to perform all functions listed if hired for this position. I recognize that, if hired, it is my responsibility to notify my manager as soon as possible if I am unable to perform any of the functions of my position for any reason. This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the job.

Exceptional People Providing Exceptional Care!

Cone Health is a state of the art network of facilities providing patients access to the latest developments in medical care from their first moments of life through later years. Our network offers the most breakthrough treatments and technology available in healthcare today. As a teaching hospital, we offer employees the opportunity to become leaders in the industry and continued growth from their first day on.

Extraordinary patient care is about being "high-touch" as well as "high-tech". Community service and superior patient care are the cornerstones of our organization, a philosophy that is demonstrated by each and every one of our valued team members. We are proud to be the largest private, not-for-profit employer of choice in the Piedmont, NC area community!

Cone Health is an equal opportunity employer. If you require assistance with our online job submission process, please contact our Talent Acquisition team at 866-266-3767 to request an accommodation. Additionally, Cone Health invites interested deaf and hard of hearing applicants to use Video Relay Service (VRS).
EXPERIENCE:
Preferred:
5 to 7 years experience of chart review

KNOWLEDGE, SKILLS AND ABILITIES:
Required:
• Must possess strong analytical skills, good communications and organizational skills.
• Must have the ability to meet tight deadlines.
• Strong projects management skills.
• Ability to work independently.

TESTING/COMPETENCY:
Testing required:
Word
Excel

PHYSICAL REQUIREMENTS:
Sedentary Work:
Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or; a negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Job are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

HEARING / VISION:
• Hear and differentiate low volume sounds in order to make judgments regarding actions needed
• Hear alarm bells, verbal conversations, telephone voices and normal volume sounds
• Close vision (clear vision at 20 inches or less)
• Distance vision (clear vision at 20 feet or more)

CONDITIONS OF EMPLOYMENT:
• Annual flu shot
• Annual TB test (if applicable to your job location)
• Annual CBL's (Safety at Work and Corporate Compliance)
• Maintain licensure/certification/registry/listing without lapse (if applicable to your job)
Share:

Similar Jobs

LPN Crossroads Psychiatric

Greensboro
Crossroads Psychiatric Group, CPG-Crossrds Psych Group Pract

RN WL Oncology West

Greensboro

Registered Nurse

Greensboro
Moses Cone Surgery Center, HSD-MC Surgery Center

RN--Emergency Department, Per Diem, Wesley Long Hospital

Greensboro
Wesley Long - Emergency Room, WLCH-Emergency Room

RN--Emergency Department, 36 hours/week, days, Wesley Long Hospital

Greensboro
Wesley Long - Emergency Room, WLCH-Emergency Room

Registered Nurse

Greensboro
Moses Cone Surgery Center, HSD-MC Surgery Center

Clinical Research Nurse II

Greensboro
Moses Cone Hospital, MHC - Cardio Vascular Research

RN--Float Pool, Weekend Option, Nights, Moses H. Cone Hospital

Greensboro
Moses Cone Hospital, MHC - Flexible Resources

RN--Float Pool, SWOT--Service Without Territory, Moses H. Cone Hospital

Greensboro
Moses Cone Hospital, MHC - Nursing SWOT

RN--Float Pool, Service Without Territory (SWOT), Moses H. Cone Hospital

Greensboro
Moses Cone Hospital, MHC - Nursing SWOT

RN MHC-Operating Room

Greensboro
Moses Cone Hospital, MHC-Operating Room

RN Unit Based Per Diem

Greensboro
Moses Cone Hospital, MHC-Operating Room

RN--Cardiovascular ICU, Relief, Moses H. Cone Hospital

Greensboro
Moses Cone Hospital, MHC-2 Heart, Cardiovascular ICU

RN--Emergency Department, 36 hours/week, 3 pm to 3 am, Wesley Long Hospital

Greensboro
Wesley Long - Emergency Room, WLCH-Emergency Room

RN--Emergency Department, 36 hours/week, nights, Wesley Long Hospital

Greensboro
Wesley Long - Emergency Room, WLCH-Emergency Room

RN (Pref Sched) - Wound Center

Greensboro
North Elam Medical Plaza Wound Center

Nursing Prof Dev Spec II - RN Residency Coord

Greensboro
Northwood Building, SW-Staff Education

RN--NEURO ICU, DAYS, 36hrs/wk, MOSES H. CONE HOSPITAL

Greensboro
Moses Cone Hospital, MC-4 North ICU

RN Unit Based Per Diem @ Wesley Long Hospital Ortho.

Greensboro
Wesley Long Hospital, WLCH-Orthopedics

RN Unit Based Per Diem- Intermediate Urology- Wesley Long Hospital

Greensboro
Wesley Long Hospital, WLCH-Intermediate Urology

RN - Relief, ICU/Stepdown, Wesley Long Hospital

Greensboro
Wesley Long Hospital, WLCH-ICU Stepdown

Stroke Response RN

Greensboro
Moses Cone Hospital, MHC-The Stroke Center

RN - CV Surgical Progressive Care, Days, Moses H. Cone Hospital

Greensboro
Moses Cone Hospital, MHC-Div 2000-Cardiac Dept