Clinical Denial RN - Clinical Performance - FT - Day

Stormont-Vail HealthCare

Topeka (KS)

Ibrido

USD 70.000 - 100.000

Tempo pieno

5 giorni fa

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Descrizione del lavoro

Stormont-Vail HealthCare seeks a Clinical Auditor/Registered Nurse to validate documentation and coding accuracy across inpatient and outpatient services. You will apply audit criteria, review medical records, and identify root causes with recommendations for change management.

The role requires a BSN (preferred), 3 years of acute care experience, and an active KSBN RN license. Hybrid work arrangement and daytime shifts support a balanced schedule.

Competenze

BSN prepared or higher preferred.
3 years acute care nursing required.
KSBN RN license required.
CDI experience preferred.
Experience with clinical audits and medical record review.

Mansioni

Collaborate with Physician Advisor on documentation improvement.
Perform root-cause analyses and recommend changes.
Review audits from inpatient, outpatient, pharmacy, and labs.
Provide feedback to health plan ops and join workgroups.
Interpret guidance for fellow auditors and staff.
Maintain audit data in the tracking database.
Educate provider services and finance on audit outcomes.
Identify trends in inappropriate utilization.
Adhere to Kansas Nurse Practice Act.

Conoscenze

Clinical audit

Root cause analysis

Change management

Collaboration

Medical records review

Formazione

BSN

Descrizione del lavoro

Position Status

Full time Shift:
First Shift (Days - Less than 12 hours per shift) (United States of America) Hours per week:
40 Job Information
Exemption Status: Non-Exempt

A Brief Overview

Performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered to patients is complete, compliant, and accurate to support optimal reimbursement and meet quality standards. Application of prospective and retrospective medical claims audit criteria, and clinical and financial review of medical records including but not limited to inpatient facility bill audits, provider offices and clinics, pharmacy and other specialties to ensure that services billed were rendered and documented, at the appropriate level, and meet quality standards. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management.

Education Qualifications

Bachelor's Degree of Science in Nursing (BSN). Preferred

Experience Qualifications

3 years Clinical experience in an acute care setting. Required
CDI experience. Preferred

Licenses and Certifications

Registered Nurse - KSBN Required

What you will do

Works collaboratively with the Physician Advisor to, documentation improvement, and medical necessity principles in performance of medical audit activity and applies principles of objectivity in performance of medical audit activity.
Perform root cause analysis and submit recommendations for appropriate change management when clinical validation audits and interpretation of medical documentation indicates lack of member access and provider involvement to manage chronic risk conditions.
Receives, reviews, verifies, and processes requests for prospective and retrospective audits including but not limited to inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews from finance and/or claims department.
Provides feedback and process improvement recommendations to appropriate health plan operations departments and participates in workgroups/committee meetings and process.
Provides clinical interpretation and guidance to fellow auditors and internal staff.
Responsible for file maintenance including entry into database for tracking and trending audit results.
Educates provider services, health services, finance, and other department staff on the outcomes of the audit results and assists provider services with educational efforts.
Provides feedback and process improvement recommendations to appropriate health plan operations departments and participates in workgroups/committee meetings and process improvement solutions as required.
Advises manager of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
Responsible for file maintenance including entry into database for tracking and trending audit results.
Maintains professional license and certifications Performs other functions as required.
Demonstrates knowledge of the Kansas State Nurse Practice Act and follows the statutes and regulations therein.
Demonstrates appropriate delegation of tasks and duties in the direction and coordination of health care team members, patient care and department activities in accordance with the Kansas State Nurse Practice Act.

Required for All Jobs

Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
Performs other duties as assigned

Patient Facing Options

Position is Not Patient Facing

Remote Work Guidelines

Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards. Stable access to electricity and a minimum of 25mb upload and internet speed. Dedicate full attention to the job duties and communication with others during working hours. Adhere to break and attendance schedules agreed upon with supervisor. Abide by Stormont Vail's Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

Hybrid

Scope

No Supervisory Responsibility
No Budget Responsibility

Physical Demands