Job Description:

The External Audit RN is responsible for the clinical medical necessity and level of care appeals for denials related to external audits by government and third-party payors. The External Audit RN is responsible for corroboration of billing and medical record documentation as it relates to the appeals process. This role will actively manage, maintain, and communicate all levels of denial and appeal activity to appropriate stakeholders, and report suspected, or emerging trends related to payer denials.

Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity and level of care rational for appeals.

•Review and interpret governmental contractors’ response letter in comparison to the medical records.

•Communicates with departmental stakeholders regarding missing or insufficient medical documentation.

Research and apply federal regulations, law, and relevant CMS policies as a basis for appeals. •Identifies and communicates root causes for denials with members of the healthcare team.

Assures all discussions and appeals are filed timely with appropriate clinical rationale.

•Completes data entry in the audit databases for tracking, trends, and analysis.

•Analyzes medical records using Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines to determine the viability of the appeal and to manage the appeal process.

Serves as a subject matter expert for documentation requirements, clinical disease processes and treatment, medical necessity decisions and appeal escalations.

•Completes ongoing education and CEU requirements to maintain licensure and certifications.

Skills

•Results focused

•Sound clinical judgement

•Effective communication (both written and oral)

•Detail-orientated

•Analytical

•Problem solving

•Spreadsheets and related analysis

•Collaboration

Qualifications

•Bachelor of Science in Nursing (BSN) preferred.

•Current licensure as a registered nurse in state of practice

•Experience in Microsoft office, electronic medical record systems and electronic databases.

Required: Three (3) years’ experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.

Preferred: Five (5) years’ experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting.

Physical Requirements

•Interact with others requiring the employee to communicate information.

•Operate computers and other office equipment requiring the ability to move fingers and hands

•See and read computer monitors and documents.

•Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment

Physical Requirements:

Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies.- and -Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.- and -Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc.- and -Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items.- and -Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling gurneys and portable equipment, including heavy items. Often required to navigate crowded and busy rooms (full of equipment, power cords on the floor, etc).- and -May be expected to stand in a stationary position for an extended period of time.

Location:

Peaks Regional Office

Work City:

Broomfield

Work State:

Colorado

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$36.35 - $54.53

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/) , and for our Colorado, Montana, and Kansas based caregivers (http://www.sclhealthbenefits.org) ; and our commitment to diversity, equity, and inclusion (https://intermountainhealthcare.org/careers/working-for-intermountain/diversity/) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

All positions subject to close without notice.