Medical Review Nurse - Home Health Auditor
RemoteUnited States
Job Summary
Conduct retrospective and prepayment audits on Home Health sector claims for Government and Commercial Payers, applying medical review guidelines, policies, and rules to determine medically appropriate services. Document findings referencing specific policies, generate letters articulating audit results, and support findings during the appeals process. Collaborate with the audit team to identify vulnerabilities, suggest workflow improvements, assist with QA functions, and cross-train in all clinical departments. Maintain abreast of medical practice changes, technology updates, and regulatory issues while managing multiple desk audits and claims reviews independently in a remote setting.
Required Qualifications
- Home Health claims auditing, quality assurance and/or recovery auditing experience of 2 years or more
- Must have Home Health experience
- An associate or bachelor's degree in nursing
- active/unrestricted RN license
- Ability to maintain high quality work while meeting strict deadlines
- Excellent written and verbal communication skills
- Ability to manage multiple tasks including desk audits and claims review
- Must be able to independently use standard office computer technology (e.g. email SharePoint, slack, outlook calendar etc.)
- Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
- Effectively work independently and as a team, in a remote setting
- Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual
- Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding
- Knowledge of insurance programs program, particularly the coverage and payment rules
Desired Qualifications
- Experience of 3 or more years
- Medical Coding certification
- CCDS - Certified Clinical Documentation Specialist
- CDIP - Clinical Documentation Improvement Practitioner
- CCS - Certified Coding Specialist
- CIC - Certified Inpatient Coder
- Strong focus on quality and attention to detail
- Deep curiosity and analytical skills to understand root causes of events and behaviors
- Proven ability to apply critical judgment in clinical determinations
- medical coding ability
- In-depth knowledge of clinical criteria and documentation requirements to support code assignments
- Understanding of ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA's Coding Clinic Guidelines
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