RN Clinical Denial Auditor

SUMMARY:

Responsible for reviewing and appealing clinical denials, tracking clinical denial trends, identifying continuous improvement opportunities. Responds to any compliance department inquiries requiring clinical expertise.  Conducts charge capture reviews as requested by payers, Patient Financial Services, and other TMCH departments to determine opportunities and provide education aimed at improving accuracy of charging practices at Tucson Medical Center (TMC).   

ESSENTIAL FUNCTIONS:

Investigates and analyzes clinical denials and medical records using medical investigative skills to determine if there is support for an appeal based on clinical evidence in the medical record, medical literature and or coding references utilizing TMC’s internal policies and procedures.

Prepares first and all subsequent appeal letters to review companies and/or plan providers. Pursues peer to peer of denials when allowed and appropriate.

Develops and drafts documents for in state Medicaid administrative hearings in collaboration with relevant TMC staff. Prepares any witnesses for administrative hearing testimony and attends the hearing with relevant witnesses.

Tracks all clinical denials to identify and develop actions on any payer trends and opportunities for improvement.

Ensures the audit request follows TMC policy guidelines; communicates directly with payer auditors to determine settlement; records data for trending.

Executes a denial management process when denials are based on medical necessity issues, providing expertise to Patient Financial Services staff by assisting with appeal development.

Researches, prepares documentation and participates in Payer audit hearings. 

Responds to payer requests for claim audits, determines whether claim meets TMC policy for audit privileges, responds to payer regarding findings, and collaborates with payer for claim settlement.

Prioritizes work effectively to meet operational deadlines.

Reads, analyzes and interprets regulatory guidelines and payer contracts to understand reimbursement methodology for various payers.

Provides clinical expertise and interprets InterQual medical necessity guidelines as applicable for evaluation of claim denials; represents TMC through participation in administrative hearings as needed to facilitate successful claim appeals.

Adheres to TMC organizational and department-specific safety, confidentiality, values policies and standards.

Performs all other duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Graduation from a qualified, nationally accredited nursing program.

EXPERIENCE:  Three (3) years of clinical nursing experience in an acute care setting. Documented experience with medical coding and/or billing systems and regulations relating to federal healthcare programs such as Medicare and AHCCCS. 

LICENSURE OR CERTIFICATION:  Current RN licensure permitting work in State of Arizona.

KNOWLEDGE, SKILLS AND ABILITIES:

·         Knowledge of medical coding and/or billing systems and regulations relating to federal healthcare programs such as Medicare and AHCCCS.

·         Knowledge of or the ability to learn, understand, and interpret InterQual medical necessity criteria and apply the criteria to inpatient claims.

·         Skill in accurately reviewing charges and training others so errors are not repeated.

·         Ability to calculate figures and compute rate, ratio, and percent; to draw and interpret bar graphs; ability to apply basic algebraic concepts.

·         Ability to apply critical thinking to carry out instructions furnished in written, oral or diagram form.

·         Ability to deal with complex problems involving several concrete variables in standardized situations.

·         Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or government regulations.

·         Ability to prepare detailed reports, business correspondence, and procedure manuals.

·         Ability to analyze and interpret regulatory guidelines and payer contracts.

·         Ability to rapidly assimilate and analyze complex information from many sources and apply principles of deductive reasoning.

·         Ability to identify medical and regulatory appealable issues and evaluate facts, regulations and research to develop concise, persuasive arguments for appeal.