Nurse Specialist II, Audit

RSource; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

Join a leading healthcare company as a Nurse Specialist II, where you'll review and appeal claims to overturn coding denials. In this remote role, you will manage documentation and collaborate with peers, ensuring quality patient care. A competitive benefits package and supportive work culture are offered.

Benefits

Medical, dental, and vision insurance

401k with company match

Generous PTO policy

Short and long term disability

Bonus opportunities

Qualifications

• Minimum of two years of experience in an acute care hospital required.
• Minimum of five years in clinical medical record audits or coding.
• Experience using InterQual and Milliman healthcare criteria preferred.

Responsibilities

• Reviews medical record documentation for audits.
• Creates detailed appeal letters for claims.
• Identifies root causes and trends in claims.

Skills

Clinical documentation review

Claims auditing

Healthcare coding

Collaboration

Root cause analysis

Education

Current and valid RN License

Tools

InterQual

Milliman

CMS guidelines

ICD-10

CPT

HCPCS codes

Job description

Career Opportunities with Knowtion Health

A great place to work.

Knowtion Health participates in E-Verify

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Are you seeking an exciting opportunity to join a passionate, growing, and dynamic team of professionals who support patients?

The Nurse Specialist II works with attorneys and claims representatives by reviewing and appealing claims when appropriate to overturn clinical validation and coding denials from Medicare, Medicaid, and other third-party payers.

What’s Attractive to the Right Candidate?

• Knowtion Health is a growing firm in a growing industry. Our status as a leader in this industry means that we have the resources to invest in the business and to innovate.
• Our business is intensely competitive and is constantly evolving. We quickly identify new challenges and develop solutions, so you won’t simply be doing what was done last year. Our new employees are frequently pleased and surprised by how quickly we make decisions and adapt to market conditions.
• Knowtion Health culture is inviting and competitive, embracing challenge and celebrating accomplishment; dedicated colleagues striving to provide quality results that have lasting impact.

The Opportunity:

• 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

What you bring:

• Current and valid RN License
• Minimum of two years of experience in an acute care hospital required
• Minimum of five years of experience in clinical medical record audits or coding
• 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
• Comfort with productivity standards

The above statements are intended to provide the general nature and level of work being performed by most people assigned to the position. They are not intended to be an exhaustive list of all responsibilities, duties and requirements.

This position is remote and requires a dedicated, distraction-free work space at home. We offer a competitive benefits package including medical, dental, vision, life insurance, short term disability, long term disability, bonus opportunities, paid holidays, 401k, and a generous PTO policy.

Knowtion Health gives priority to applicants located in the following states: AR, AL, AZ, FL, GA, IL, KS, KY, MD, MA, MN, NC, OH, OK, PA, SC, TN, TX, WV, VA