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Revenue Integrity Auditor job in Tampa at Shriners Hospitals For Children

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Job Requirements


EXPERIENCE REQUIRED/PREFERRED: 

  •  3 years of clinical hospital experience required
  • Clinical auditing experience required
  • Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies required
  • Experience working collaboratively with IT, HIMS, Finance, Compliance, Managed Care, Business and Clinical Operations required
  • Experience with reviewing hospital claims, denials and EOB's, appealing claims and working on claims in an audit is preferred.

 EDUCATION REQUIRED/PREFERRED: 

  • High School Degree or GED required
  • Bachelor’s degree desired
  • RN highly preferred.  If RN, current RN License required – BSN highly desired. If RN, must have a current nursing license in the state of employment.

KNOWLEDGE, SKILLS & COMPETENCIES: 

  • Knowledge of hospital clinical practice standards for health care providers.
  • Knowledge of ancillary service departments, quality control and safety standards.
  • Proficient in criteria sets used to determine eligibility for acute care hospitalization.
  • General familiarity with medical record coding systems.
  • Functional knowledge of DRG and CPT coding systems.
  • Knowledge of third party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
  • Demonstrates ability to communicate in writing and verbally in an effective manner. Effective communication includes ability to spell accurately and write legibly.
  • Must be proficient in mathematical skills.
  • Must be detail-oriented
  • Must have ability to organize and prioritize
  • Working knowledge of Microsoft computer applications (Excel, Word, PowerPoint, etc.)
  • Working knowledge of 3M system
  • Excellent written, verbal and presentation skills required; excellent business judgment, decision making, and business savvy are also essential.
  • Strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process.
  • Knowledge of applied statistics, process analysis, and outcomes analysis.

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Revenue Integrity Auditor at Shriners Hospitals For Children

Revenue Integrity Auditor

Shriners Hospitals For Children Tampa, FL, FL Full-Time
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The Revenue Integrity Auditor is responsible for auditing claims and charges to ensure compliance with all State and Federal guidelines and regulations, appeals of clinical issues on claims, assisting with the review, analysis and resolution of denied, under-paid, and audited claims, coordinating efforts related to payer audits, and providing feedback to hospital charging departments on documentation, charges and charge master coding. The Revenue Integrity Auditor is responsible for maintaining a detailed knowledge of Medicare RAC and corresponding Medicaid Audit procedures, as well as responsible for review and compliant filing of responses to all audit requests to include Governmental Audits. The Revenue Integrity Auditor responsible for analysis and interpretation of Third Party Payors and Governmental Payors clinical/medical necessity denials, as well as filing compliant appeals in accordance with Third party and governmental contracts.

POSITION RESPONSIBILITIES :

  • Performs an audit of assigned cases comparing the bill to the medical record.
  • Performs a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process
  • Performs a detailed comparison of charges to documentation to ensure services not documented are not charged.
  • Reviews documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur
  • Review findings with the hospital representatives and obtains an agreement on the discrepancies.
  • Demonstrates tact and understanding in handling problems, has a good rapport with hospital and corporate staffs.
  • Initiates scheduling of the audit with in 48 hours of receipt of the claim.
  • Reports to the Revenue Integrity Manager the audit status and initial findings within 24 hours of schedule date.
  • Follows up on re-audits in a timely fashion to ensure that cases are completed.
  • Reviews audit worksheets and charge totals by category with the bill to ensure a match.
  • Re-checks mathematical computations before finalizing letter and report.
  • Updates status of all cases assigned on minimum weekly basis
  • Informs supervisor of any changes, problems, or concerns that arise at a facility.
  • In the event of a dispute with the requesting party’s audit findings, files an appeal with the third party or governmental payor
  • Analyzes and interprets all medical necessity/clinical denials from third party payors or governmental payors.
  • Files appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria.

EXPERIENCE REQUIRED/PREFERRED: 

  •  3 years of clinical hospital experience required
  • Clinical auditing experience required
  • Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies required
  • Experience working collaboratively with IT, HIMS, Finance, Compliance, Managed Care, Business and Clinical Operations required
  • Experience with reviewing hospital claims, denials and EOB's, appealing claims and working on claims in an audit is preferred.

 EDUCATION REQUIRED/PREFERRED: 

  • High School Degree or GED required
  • Bachelor’s degree desired
  • RN highly preferred.  If RN, current RN License required – BSN highly desired. If RN, must have a current nursing license in the state of employment.

KNOWLEDGE, SKILLS & COMPETENCIES: 

  • Knowledge of hospital clinical practice standards for health care providers.
  • Knowledge of ancillary service departments, quality control and safety standards.
  • Proficient in criteria sets used to determine eligibility for acute care hospitalization.
  • General familiarity with medical record coding systems.
  • Functional knowledge of DRG and CPT coding systems.
  • Knowledge of third party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
  • Demonstrates ability to communicate in writing and verbally in an effective manner. Effective communication includes ability to spell accurately and write legibly.
  • Must be proficient in mathematical skills.
  • Must be detail-oriented
  • Must have ability to organize and prioritize
  • Working knowledge of Microsoft computer applications (Excel, Word, PowerPoint, etc.)
  • Working knowledge of 3M system
  • Excellent written, verbal and presentation skills required; excellent business judgment, decision making, and business savvy are also essential.
  • Strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process.
  • Knowledge of applied statistics, process analysis, and outcomes analysis.

Recommended skills

Clinical Auditing
Hospital Claims
Utilization Review
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Job Snapshot

Employee Type

Full-Time

Location

Tampa, FL, FL

Job Type

Health Care

Experience

3 years

Date Posted

02/18/2021
Apply to this job.
Think you're the perfect candidate?
Apply Now