Audit Reviewer
Remote · Conway, Arkansas, United States or US
Job Summary
The Audit Reviewer works with claims representatives by reviewing and appealing claims when appropriate to overturn clinical validation and coding denials from Medicare, Medicaid, and other third-party payers. Reviews medical record documentation to verify clinical indicators and coding issues as related to DRG Validation Audits, Emergency Department Downgrade Audits, Inpatient Level of Care Audits, and Charge Outlier Audits, etc. Creates detailed appeal letters for denials from payer to support payment of patient claims. Manages Inventory and Follow up on accounts as appropriate. Reviews InterQual/Milliman, coding guidelines and/or payer medical policies related to denied procedures or services and includes criteria in appeals letter as appropriate. Provides feedback to supervisor regarding issues identified for ongoing training to peers and non-clinical staff members. Identifies root causes and trends to share with clients and staff. Works with peers in collaboration of clinical writing situations.
Required Qualifications
- Current and valid RN License or Coder with 3 years inpatient experience
- Two years of experience in an acute care hospital (Med/Surg) preferred
- Five years of experience in clinical medical record audits or coding preferred
- Experience using InterQual and Milliman healthcare criteria preferred
- Experience reviewing CMS LCD/NCD criteria preferred
- Knowledge of CMS and payer reimbursement guidelines preferred
- Knowledge of DRG, ICD-10, CPT and HCPCS codes preferred
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