Intermountain Healthcare Nurse Auditor - Select Health - Registered Nurse - Medical Coding in Murray, Utah
Greater Salt Lake area
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This position utilizes clinical expertise, expert coding knowledge and critical thinking skills to work collaboratively with SelectHealth's medical directors, internal and external compliance functions and healthcare provider partners to ensure medical necessity and accurate coding in compliance with NCQA's and other regulatory agencies' standards and turnaround requirements. This position also performs provider appeals process to research and notify of claims and coverage decisions made by SelectHealth's medical directors and compliance functions.
Essential Job Duties
- Reviews and audits medical records in association with medical claims and provider appeals for appropriate CPT, ICD-9 (ICD-10) coding and for medical necessity utilizing clinical expertise, assessment of patient and medical documentation and coding knowledge and skills.
- Utilize critical thinking skills to conduct regulatory comparison with submitted claims and coding with Centers for Medicare and Medicaid (CMS), Current Procedural Terminology (CPT), National Correct Coding Initiative (NCCI), Medicaid state requirements and National Committee for Quality Assurance (NCQA).
- Ensure claims are reviewed and released within ERISA (Employee Retirement Income Security Act) standards for turnaround time.
- Analyzes provider appeals for trends in inappropriate coding, fraudulent billing patterns, and opportunities for physician education. Reports and coordinates with other departments for appropriate action and educates providers on incorrect use of codes and support them in correcting documentation and billing inaccuracies.
- Consults with physicians and providers offices on coding denials, edits and reviews. Coaches physicians and office staff on policies and processes to avoid future denials.
- Facilitates review and creation of medical, coding and reimbursement policies for consistent and appropriate review of submitted claims, appeals and medical records.
- Monitors, maintains, and initiates changes in system set up to maintain compliance with coding regulations and edits.
- Administer plans consistent with benefits and Certificates of Coverage filed through State Departments of Insurance.
- Maintains current critical knowledge of coding required to administer auditing functions.
- Gains and maintains knowledge on current/future national, regional and local healthcare coding regulations. Train and mentor new or existing staff. Provides external provider training on coding regulations and billing practices.
- Demonstrates a comprehensive understanding of SelectHealth?s internal processes and procedures.
- Demonstrates excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physician, office staff and other external and internal customers and departments.
- Benefits Eligible: Yes
- Shift Details: FT, 40hrs/wk.
- Department: Select Health
- Bachelor's degree in Nursing (BSN) from an accredited institution. Intermountain verifies both degree attainment and educational institution accreditation following an offer of employment.
- Currently licensed as a Registered Nurse (RN) in the State of Utah.
- Current coding certification from a nationally recognized organization (e.g. American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)) or will receive within 1 year of hire.
- Five years of clinical experience
- Experience on word processing, internet searches and spreadsheets.
- Ongoing need for employee to see and read information, assess member needs, and view computer monitors.
- Frequent interactions with providers, members that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues accurately
- Manual dexterity of hands and fingers, this includes frequent computer use and typing for documenting member care, accessing needed information, etc.
- Three years of health insurance experience.
- Experience in training and auditing procedures.
- Clear understanding of health care products.
- Demonstrated teaching and leadership ability.
- Ability to communicate successfully, professionally and effectively with all individuals, professional and private, in writing and verbally.
- Ability to establish and maintain rapport with co-workers, physicians, other health care providers and clients.
- A working knowledge of managed care, ICD-9/CPT 4 coding, length of stay guidelines, and appropriate levels of care and modalities by diagnosis/procedure in multiple clinical areas.
- Able to work independently, and be self-motivated with a positive attitude and flexibility in a rapidly changing environment.
All positions subject to close without notice. Intermountain Healthcare prohibits discrimination on the basis of race, ethnicity, religion, color, national origin, sex, age, sexual orientation, gender identity/expression, veteran status, disability and/or genetic information.
Working Hours 40
Primary Work Location SelectHealth - Franklin, SelectHealth - Murray
Job Type Full Time