RN Clinical Auditor

Thank you for considering a career at Ensemble!

Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.

Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!

O.N.E Purpose:

• Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

• Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

• Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity:

CAREER OPPORTUNITY OFFERING:  

• Bonus Incentives  

• Paid Certifications  

• Tuition Reimbursement  

• Comprehensive Benefits  

• Career Advancement  

• This position pays between $63,100.00 - $108,900.00 based on experience  

The RN Clinical Auditor performs complete government (MAC, CERT, RAC, OIG, ZPIC, UPIC, QIO, TPE, DRG), state (Medicaid, PERM) and commercial (Managed Medicare, Charge/Defense, Level of Care, Medical Necessity, Readmission) payer clinical audit reviews on assigned Clinical Audits, DRG Clinical Validation Audits, and clinically related claims as objectively and accurately as possible to uphold quality, compliance and performance standards across Ensemble Health Partners. The Clinical Auditor RN assists with analyzing and reviewing clinical audit and DRG clinical validation audits to prevent future audits by providing clinical records to payers, contacting government and payer agencies, contacting physician offices, and preparing for physician advisor reviews.

Job duties include but are not limited to contacting regulatory bodies such as MACs (Medicare Administrative Contractors) and payers to determine the reason for the audit, reviewing audit letters, analyzing claims, reviewing for compliance rules and regulations, gathering appropriate medical records from client EMR per government requirements, determining if an audit is necessary, preparing the audit materials. The Clinical Auditor RN will work in tandem with Ensemble/Client compliance educate other departments (PA, HIM, case management, client departments, revenue integrity, coding, CDI, etc.) on any audit outcomes and assist in developing action plans for prevention. The primary goal of the RN Clinical Auditor is to ensure the delivery of high-quality, cost-effective reviews and to minimize financial risk to Ensemble Health Partners and clients. This role involves a combination of clinical expertise, data analysis, exceptional communication abilities, and regulatory/compliance knowledge to maintain and improve healthcare standards.

Job Responsibilities:

Review Clinical Audits:

• Have in-depth knowledge of clinical nursing practices and clinical procedures. And an understanding of medical coding and billing (DRG, CPT, ICD-10) along with an understanding of CMS rules and regulations concerning governmental audits including knowledge of CMS polices, Local Coverage Determinations, National Coverage Determinations, and Billing Articles and ability to review within electronic medical records.
  • Review medical records to ensure compliance with healthcare standards and regulations
  • Validate accuracy and appropriateness of services given
  • Record audit determinations using Ensemble Health Partners audit tracking system and document
  • Preparing the necessary materials for an audit response.
  • Collecting all relevant patient medical records that are requested for the audit
  • Make sure all documents are complete, accurate, and signed by the appropriate healthcare provi