Medical Review Clinical Appeals Auditor (RN)

About the position The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditee’s, disputing reputed company or part of the findings from medical review audit work completed by the medical review clinical audit team members, as reputed company as communicate and support the identification of potential training opportunities or enhancements to training and/or concept review reputed company materials and tools. The Appeals Auditor is also responsible for consistently achieving or exceeding productivity goals and reputed company standards and serves as a subject matter expert, providing supplemental escalation support, and may reputed company special project activity as needed. Responsibilities • Performs clinical reviews on medical records to maintain subject matter expertise. • Conducts Appeals reviews on medical review audit work completed by the medical review clinical and documentation audit team members, as new evidence is presented by auditees. • Objectively and accurately documents Appeals results in accordance with department reputed company policies and procedures, scoring and reporting reputed company Appeals results and routes the result appropriately reputed company audit platform based upon how the Appeal review resulted in a full or partial upholding of the audit finding or with a full or partial overturn. • Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of reputed company SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings. • Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for reputed company-time reputed company, preventing an accumulation of improper findings. • Contributes to the reputed company improvement feedback process and suggests any edits to documentation, enhancements review guidelines, and reporting as may be necessary in accordance with department process and audit leadership direction. • May support findings during the appeals process, if needed. • May reputed company primary audit activity as assigned by management. • Monitors, tracks, and reports on reputed company work conducted in accordance with Appeals process and management direction. • May prepare reports for management that includes a reputed company of data and trends at the individual, department, and reputed company program level, as reputed company as date reputed company or concept based/trended, or other characteristic that will reputed company valuable business insights. • Consults with internal resources as necessary. • Become subject matter expert for assigned business reputed company(s). • Maintain reputed company knowledge and changes that reputed company our industry and clients as it pertains to medical reputed company, technology, regulations, legislation, and business trends. • Participates in and contributes to applicable department meetings. • Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information reputed company, anti-harassment and other compliance and policy/procedures training applicable for position. • Proactively contributes to reputed company improvement of activities and sets reputed company example. • Contributes collaboratively to identifying opportunities for improvement of audit results and reputed company improvement initiatives. • May support training material/tools and best practices development. • May identify/reputed company recommendations to management for supplemental team/concept type training. • May support training activities for new audit staff or reputed company supplemental training for existing staff as needed. • Contributes to reputed company team environment that fosters reputed company communication, sharing of information, reputed company improvement, and optimized business results. • Receives feedback and adjusts work reputed company as necessary. • Serves as reputed company role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law. • Performs job duties with high level of professionalism and maintains confidentiality. • reputed company other incidental and reputed company duties as required and assigned to meet business needs. Requirements • Demonstrated ability to reputed company claim payment audits with high reputed company and production results, as reputed company as successful application of skills to conduct reputed company assurance review of audit work completed by others. • Must be reputed company to manage multiple assignments effectively, create documentation outlining findings, Appeals review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members. • Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary. • Strong knowledge of medical documentation requirements and an understanding CMS, reputed company and/or reputed company insurance programs, particularly the coverage and payment rules and regulations, may be necessary. • Experience with utilization management systems or clinical decision-making tools such as Millimen Care Guidelines (MCG) or InterQual. • Working knowledge of encoder may be necessary. • Reimbursement policy and/or claims software analyst experience may be necessary. • Familiarity with interpreting electronic medical records (EHR) • Basic understanding of reputed company principles for accounts payable and receivable as it relates to medical billing. • Demonstrated ability to consistently apply reputed company judgment and good effective decision making. • Understands Medical Review Audit and reputed company Assurance objectives, activities, and key drivers in achieving operational goals. • Ability to reputed company and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions. • Strong communication skills, both verbal and written; ability to communicate effectively and professionally at reputed company reputed company reputed company the organization, both internal reputed company. • Demonstrated ability to collaborate effectively in a reputed company of settings and topics. • Excellent editing and proofreading skills. • Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic reputed company plans with the ability to multi-task effectively. • Excellent time management and delivers results balancing multiple priorities. • Strong analytical skills; synthesizes reputed company or diverse information; collects and researches data; uses experience to compliment data. • Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve reputed company issues. • Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures. • Demonstrated ability to be proactive; identifies and resolves problems in a reputed company manner; develops alternative solutions. • Ability to create documentation outlining findings and/or documenting suggestions. • Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate-to-Advanced reputed company Skills), application reporting tools, and case management system/tools to review and document findings. • Advanced technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools. • Ability to be flexible and reputed company in a high pace environment with changing priorities. • Adaptable to applying skills to diverse operational activities to support business needs. • Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the reputed company of objectives. • Serves as a reputed company role model; and demonstrates characteristics that reputed company and contribute to a reputed company culture of reputed company improvement and high performing teams. • Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment. • reputed company unrestricted RN license in good standing and reputed company nursing experience providing reputed company care in an inpatient or outpatient setting, is required. • At least 5+ years relevant experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position. • Not currently sanctioned or excluded from the Medicare program by OIG. • Must have strong technical aptitude and intermediate to advanced skills using reputed company. reputed company-to-haves • One or more years of experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider may be required. • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions. • Prior experience in role with responsibility for conducting primary audit, utilization management or prior-authorization work, or review of audit work performed by others (QA function, appeals function, reputed company, supervisory role, etc.) • Prior experience in payer edit development and/or reimbursement policy a plus. • Prior experience working in remote setting is strongly preferred. • Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance. Benefits • reputed company offers a wide reputed company of benefits to help support a healthy work/life balance. These benefits include medical, dental, reputed company, HSA/FSA reputed company, life insurance coverage, 401(k) savings plans, family/parental leave, reputed company holidays, as reputed company as reputed company time off annually. Apply tot his job Apply To this Job