What are the responsibilities and job description for the Revenue Integrity Clinical Auditor position at SCP Health?
At SCP Health, what you do matters
As part of the SCP Health team, you have an opportunity to make a difference. At our core, we work to bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, 30 states, and 400 healthcare facilities, SCP Health is a leader in clinical practice management spanning the entire continuum of care, including emergency medicine, hospital medicine, wellness, telemedicine, intensive care, and ambulatory care.
Why you will love working here:
- Strong track record of providing excellent work/life balance.
- Comprehensive benefits package and competitive compensation.
- Commitment to fostering an inclusive culture of belonging and empowerment through our core values - collaboration, courage, agility, and respect.
Responsibilities:
- Perform a thorough review of the medical records for both emergency department and hospital medicine denials and extract pertinent clinical data to support the billed CPT code.
- Creates a high-quality complex written clinical review summary for emergency department and hospital medicine denials utilizing the pertinent clinical data to support the billed CPT code.
- Prioritize ETM view by timely filing guidelines (for medical necessity denials).
- Analyze non-medical necessity denials and determine appropriate outcomes.
- Must maintain a thorough understanding of CMS Documentation guidelines, ProCode CDR and payer policies. Must apply this knowledge when drafting clinical appeals.
- Send invoice list for appeals to supervisor for letters and forms to be generated for appeals.
- Prepare Level 2 Reconsideration Appeal packet which includes Cover Letter, Special Forms, CRJ, EOB, Medical Records; submit to payer via appropriate method (Fax, Mail, Upload).
- Enter task notes and outcomes in ETM to document work and capture production numbers.
- Resubmit medical records/appeals that were not originally received (from Redeterm team).
- Invoice analysis to identify appeals with delayed payer response that will require phone calls. Phone call to payers about status of claims if no correspondence or rejection code received.
- When coding variances identified, escalate invoice to ProCode for possible coding variance/charge corrections/coder education.
- Assist with any other special projects assigned by supervisor as needed
- Stay abreast of Medicare, Medicaid, and Commercial payers’ laws, regulations, policy and procedures for appeal submissions and timely filing deadlines
What we are looking for:
- Diploma or certificate program earning an LVN or LPN OR Bachelor of Science in nursing or bachelor or associate degree in Health Information Management
- Heath Information Management or Nursing required
- 3 years clinical, case management or utilization review experience in health care setting or 3 years coding experience.
- RN, LPN, RHIA or RHIT required
- Knowledge of Emergency Department and Hospital Medicine coding guidelines.
- Knowledge of Centers for Medicare and Medicaid Services (CMS) coding and billing requirements.
- Significant skills in business applications
- Excel, Word, PowerPoint
- Must be well organized and demonstrate effective time management skills
This position is eligible for our corporate benefits, please click this link for the details: https://myscpbenefits.com/
To learn more about SCP Health, please visit:
www.scphealth.com
SCP Health is an Equal Opportunity Employer.
www.scp-health.com
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