Registered Nurse CRC Coding Auditor - REMOTE

JOB SUMMARY 

The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines.  The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter.  The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.                        

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG’s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Effectively organizes work priorities
• Demonstrates compliance with departmental safety and security policies and practices
• Demonstrates critical thinking, analytical skills, and ability to resolve problems
• Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
• Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
• Possesses excellent written and verbal communication skills
• Detail oriented and ability to work independently and in a team setting
• Moderate skills in MS Excel and PowerPoint, MS Office
• Ability to research difficult coding and documentation issues and follow through to resolution
• Ability to work in a virtual setting under minimal supervision
• Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment.  This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Includes minimum education, technical training, and/or experience required to perform the job.

Education

• Minimum Required:
  • Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment
  • RN License in the State of Practice
  • Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
• Preferred/Desired:
  • Completion of BSN Degree Program 
  • CCDS certification or inpatient coding certification

Experience