Senior RN - Perioperative Clinical Case Auditor/Coordinator

We are recruiting for a motivated Senior RN - Perioperative Clinical Case Auditor/Coordinator to join our team!

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Department

Perioperative Bus Svc (Admin)

Job Summary
Under general supervision, the Senior RN Perioperative Clinical Case Auditor/Coordinator, serves as a clinical liaison to over 100 surgeons and over 30 specialty surgical services. Executes rigorous clinical audits of surgical case orders and reconciliation of complex clinical Inpatient, elective and urgent surgical procedures, and documentation; with the aim of identifying gaps and recommends changes to clinical practices to ensure optimum care is delivered to all surgery patients, ensuring accuracy and compliance with various Hospital, State, and Insurance regulations. Ensures alignment of proper CPT codes against selected surgical procedures which benefits the overall insurance pre-authorization and reimbursement to maximize cost effective outcomes while increasing the department/hospitals overall reimbursement. Serves as a clinical educator, providing education, development and clinical feedback to the Surgeons, surgery service leaders and Surgery Schedulers regarding documentation and coding. Partners with the Providers, service leaders, and Epic Analysts to update/amend and maintain the Base Procedure List (BPL) for all surgical procedures. Provides New Products Committee with Financial/RVU (Relative Value Units) for reimbursement data and utilizes knowledge of both Nursing and administrative practices to perform charge audits while adhering to clinical guidelines to ensure best outcomes for surgical patients and increased revenue for Perioperative Services.

Essential Functions:

• Audits and Coordinates:
  • Executes rigorous clinical audits of surgical case orders and reconciliation of complex clinical Inpatient, Elective and urgent surgical procedures and documentation; with the aim of identifying gaps and recommends changes to clinical practices to ensure optimum care is delivered to all surgery patients.
  • Has independent oversight and decision-making authority to ensure alignment of proper CPT codes against selected surgical procedures which benefits the overall insurance pre-authorization and reimbursement to maximize cost effective outcomes while increasing the department and hospitals overall reimbursement.
  • Reviews all surgical case orders to determine the best alignment of Clinical Diagnosis to align with the patients LOS (Length of Stay) and accurate patient classification.
  • Ensuring surgical case orders are accurate and in compliance with various hospital, State and insurance regulations.
  • Performs data integrity and quality checks of surgical case orders to ensure adherence of industry best practices and HIPPA compliance.
  • Conducts other projects, including ad hoc audits or investigations pertaining to industry best practices, surgical case orders within Perioperative Services and connecting ancillary departments. (50%)
• Documentation and Reporting:
  • Exhibits a strong clinical background along with a thorough understanding and knowledge of the Base Procedure List (BPL) for all surgical procedures to document steps in collecting proper surgical procedures and revenue collection alignment.
  • Provides 'New Products Committee' with financial and RVU (Relative Value Units) for reimbursement data to assist with vetting, onboarding and decision making for all new product requests for the Perioperative Department.
  • Must utilize knowledge of both nursing and administrative practices to perform charge audits while adhering to clinical guidelines to ensure best outcomes for surgical patients and increased revenue for Perioperative Services.
  • Advises and steers Providers to determine surgical procedures needed for each specialty service line in alignment with the appropriate CPT code.
  • Captures data and utilizes said data to facilitate process improvement recommendations and standard work documentations and implementation while allowing for maximum billing and reimbursement along with accurate procedure selection.
  (30%)
• Collaborates and Communicates:
  • Serves as a clinical educator providing educational development and clinical feedback to the Attendings, surgery service leaders and Surgery Schedulers, regarding documentation and coding for all surgical procedures in conjunction with the patient's classification, procedures selection and CPT code assessment.
  • Reports adverse findings to Perioperative leadership for educational and learning opportunities while making recommendations for process