RN Clinical Auditor

Neighborhood Health Plan of Rhode Island; Smithfield (RI); Sur place; USD 75 000 - 110 000; Plein temps

Résumé du poste

Neighborhood Health Plan of Rhode Island seeks an RN Clinical Auditor to conduct comprehensive reviews of claim data and medical records for Fraud Waste and Abuse investigations within the SIU. You will use data mining tools and payment/case systems to identify aberrant billing patterns and validate services provided according to policy and regulations.

Responsibilities include planning audits, preparing investigative summaries, notifying providers, supporting recoveries, and communicating

Qualifications

• Active RN license in RI with good standing.
• Experience with healthcare coding and clinical documentation.
• Knowledge of fraud, waste and abuse concepts and regulations.

Responsabilités

• Plan and perform audits and investigations focused on FWA.
• Utilize data mining tools to identify outliers and leads.
• Obtain and review medical records to validate services.
• Prepare investigative summaries and notify providers of findings.

Connaissances

Healthcare coding knowledge

Data mining tools

Regulatory compliance

Communication skills

Confidentiality

Formation

Registered Nurse license (RI)

Auditing certification (CCS/CPC/CPMA/AHFI)

Outils

Microsoft Office

Description du poste

Responsible for conducting comprehensive review of claim data and /or medical record documentation related to Fraud Waste and Abuse (FWA) investigations opened by the Special Investigations Unit (SIU) from various internal and/or external sources. Position requires use of computer-based data mining tools, claim payment and case management systems to identify aberrant or potentially fraudulent billing patterns. The RN Clinical Auditor will obtain and review medical record documentation to validate authorized, billed and paid services were provided according to State and Federal regulations/guidelines, Neighborhood benefit coverage and payment policies, medical necessity and standards of care. This role works collaboratively with the entire SIU team and communicates with internal business areas as applicable related to the case as well as external State and Federal regulatory and law enforcement agencies as necessary.Duties and Responsibilities:Responsibilities include, but are not limited to:Plan and perform audits and investigations focused on detecting and preventing fraud waste and abuse utilizing knowledge of CPT, ICD, HCPS coding guidelines and regulations, benefit coverage, clinical medical and payment policies.Utilize various data mining tools to proactively identify outliers and potential case leads.Identify aberrant billing patterns resulting in overpayments or potential fraudulent activity.Obtain and review medical record documentation to prepare comprehensive clinical review/investigative summaries per SIU Standard procedures.Notify provider(s) of findings and provide feedback and education as necessary. Respond to appeals, prepare settlement agreementsPrepare accurate reporting to recoupment staff to initiate recovery of overpayments. Refer to Legal department as necessary for assistance with recoveries from non-responsive providers.Manage caseloads independently with attention to established timelines for casework ensuring timely follow up, audit completion and submission of recoupments and/or allegation of fraud to regulatory oversight agenciesMaintain documentation of case work per SIU standard policies and procedures to support mandated reporting Core Contract reporting for EOHHS.Work collaboratively with and providing case updates on progress of investigations to management, SIU and Compliance team members, internal business leads related to case and external agencies as necessary.Communicate investigative findings and provide testimony in legal proceedings as required.Assist with RFI’s from external Regulatory and Law Enforcement agencies.Assist with education on fraud and abuse awareness, detection and reporting to business areas as required.Take responsibility for professional development, support a learning environment, and meet professional competency requirements.Perform other duties as assignedQualifications Required:Registered Nurse with an active, current, unrestricted license in RI in good standingMinimum of three (3) years experience in healthcare coding directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing, or health care quality improvementKnowledge of clinical medical record documentation requirementsA high-level knowledge of medical terminologyProficient with various technology software tools, including Microsoft OfficeExcellent written and verbal communication skills, and strong attention to detailAbility to maintain confidentialityAbility to take direction and support a multitude of individualsAbility to work independently and prioritize activitiesPreferred:Working knowledge of fraud, waste and abuse policies and practicesEvaluation and management coding and auditing expertiseKnowledge of Behavioral Health billing & coding guidelines and/or regulatory guidelinesElectronic medical record review experienceElectronic investigative case management and/or healthcare claims data mining tool experience.Certified Coding Specialist (CCS), Certified Coding Specialist Provider-based (CCS-P), Certified Professional Coder (CPC or CPC-H), CPMA or equivalent certification.Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certificationNeighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status