Job Description

Under direct supervision of the Manager, RN Auditor, the RN Auditor is responsible for the review of medical record documentation for accuracy, and completeness in regard to compliance with all Federal and State regulatory bodies, Medicare, and Medi-Cal programs by analyzing ADT documentation, Business Office notes and Case Management clinical reviews through intensive medical record review.

Core Competencies

• Ensures other requirements from a regulatory perspective such as delivery of the “Medicare Important Message” are met.
  
  
• Ensures all other clinical documents meet regulatory requirements as it relates to date, time and signature.
  
  
• Performs concurrent and retrospective review of Medicare and MediCal and other payors patient’s electronic and paper charts for correct patient status and appropriate admissions transfer and discharge physician orders.
  
  
• Verifies billing system for correct status prior to bill being approved and submission of daily adjudication reports.
  
  
• Applies appropriate clinical criteria (i.e. MCG) when reviewing medical records either concurrently or retrospectively.
  
  
• Works collaboratively with other hospital departments regarding ongoing employee education for correct data entry of ADT orders within the Medical Center.
  
  
• Understands the responsibilities of the Physician Advisors as the first and second level professional review organization within the Medical Center.
  
  
• Acts as a change agent by recognizing patterns and identifying opportunities for interdepartmental process improvement.
  
  
• Identifies and refers accounts meeting established criteria to the Utilization Review Committee.
  
  
• Documents audit finding such as: correct account status; level of care changes; etc., if applicable, on the Billing Audit form.
  
  
• Assists with RAC preparation.
  
  
• Assists in gathering documentation necessary to respond to the initial data requests and any subsequent appeals.
  
  
• Participates in department and hospital Performance Improvement (PI) activities.
  
  

Education

DegreeProgramAssociatesNursing

Experience

Number of Years ExperienceType of Experience5Case Management and/or Utilization Management experience.
Additional InformationRequires a working knowledge of CMS guidelines and related healthcare industry standards. Must have clinical documentation, medical necessity and/or utilization management review experience.

License / Certification Requirements

Registered Nurse LicenseANCC Certification within a year of hire

Compensation Range

$48.77 - $81.51 / Hour