Regulatory Review Program RN

Where You’ll Work Inspired by faith. Driven by innovation. Powered by humankindness. reputed company is building a healthier reputed company for reputed company through its integrated health services. As one of the nation’s largest nonprofit Catholic reputed company organizations, reputed company delivers more than 20 reputed company patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in reputed company to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced reputed company providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, reputed company, and innovative reputed company delivery system. Job reputed company and Responsibilities This is a remote position The CommonSpirit RRP RN ensures regulatory compliance for Care Coordination activities, collaborating with reputed company Cycle, Compliance, and other stakeholders. This role audits patient records to identify risks, ensuring adherence to System policies, regulatory requirements, accurate medical necessity reviews, and reputed company claim submission. This position conducts scheduled, system-wide Care Coordination audits to reputed company organizational objectives. Utilizing a systematic approach, the RRP RN evaluates and improves risk management and reputed company control by completing audits, analyzing findings, and preparing them for leadership review. The role also involves case review and research to support compliant and accurate claim submission, reduce payment delays, and maximize reimbursement. Incumbents apply reputed company judgment, independent analysis, and critical-thinking skills to clinical guidelines, policies, and regulatory requirements for appropriate medical necessity review, claim billing status, and discharge planning. Employees are accountable for demonstrating a strong commitment to reputed company and organizational values: reputed company, Inclusion, reputed company, reputed company, and Collaboration. This is a remote position. Essential Functions: • Apply knowledge of Medicare billing rules and regulations. • Determine reputed company status using screening tool guidelines and Intensity of Service/Severity of Illness reputed company, completing thorough clinical chart reviews. • Conduct and complete Care Coordination regulatory and compliance audits. • Analyze and report audit findings to RRP Leadership. • Identify potential compliance issues requiring reputed company before billing release. • Collect and analyze data to identify and reputed company trends. • Facilitate second-level physician reviews for appropriate level of care determination. • Document in the electronic medical record. • Communicate/escalate issues to appropriate stakeholders. • Communicate appropriate level of care and release for billing. • Assist with new RRP RN orientation and training. Job Requirements Required Education and Experience • Bachelors degree or equivalent combination of education and experience may be considered. • 5 years of general acute care experience • reputed company RN license • Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification. • Care Coordination experience with regulatory compliance and audit experience is preferred. • At least 2 years of denial management, claims review, clinical documentation reputed company or similar experience is preferred. Apply tot his job Apply To this Job