Intermountain Healthcare RN SIU Clinical Auditor - SelectHealth (Full Time) in Salt Lake City, Utah
Greater Salt Lake area
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Reviews and challenges large-dollar claims. Reviews bills from providers to assess whether charges are appropriate and reasonable, reviews for billing errors, and identifies cost containment opportunities for lowering medical expense and to maintain National Committee Quality Assurance (NCQA) accreditation. Assists the Sr. Clinical Auditor(s) in performing focused audits.
Essential Job Duties
- 1. Reviews Audits large-dollar claims using medical records, internal documentation and policies, coding guidelines, and applicable contracts to determine that claimsthey are processed correctly according to plan agreements.
- 2. Maintains appropriate documentation of individual each claims auditedreviewed.
- 3. Identifies cost containment opportunities including, but not limited to, fraud, waste and abuse..
- 4. Communicates findings from reviews audits to management.
- 5. Assists in the preparation of quarterly reports summarizing findings (e.g., dollars saved, system weaknesses, practice patterns) to be submitted to management.
- 6. Educates personnel regarding cost containment opportunities.
- 7. Prepares and submits files for physician review.
- 8. Maintains current coding certification and RN license.
- 9. Maintains National Committee Quality Assurance (NCQA) accreditation compliance standards related to all products.
- 10. Works cooperatively with management, team and external clients to lower medical expense through audit findings.
- 11. Maintains proficient knowledge in all lines of business.
- 12. Researches and interprets current medical literature and procedures in an effort to interpret medical records and policies during audits.
- 13. Certified Professional Coder (CPC) or equivalent professional coding certificate or American Health Information Management Association (AHIMA) related coding certificate and a thorough understanding of coding issues OR obtain Certified Coder designation within 1 year of hire date. If not obtained within the time period the employee will be removed from the position.
- Benefits Eligible: Yes; Medical, Dental, Vision, Education Assistance. Click here for more details
- Shift Details:Full time, 40 hours per week. Monday through Friday 8AM-6PM.
- Department: Care Management - SelectHealth
- Additional Details: RN License and Billing Coding/Medical Record Auditing Experience Preferred.
- Bachelor's degree in healthcare related field (clinical or operations) from an accredited institution, which will be verified.or RN license in the State of Utah, and four years clinical experience.
- Five years of experience in managed medical or behavioral health care directly related to determining appropriate diagnosis and procedure codes used in billing for services, utilization management, medical record auditing, or health care quality improvement gaining knowledge reading and interpreting complex medical records and experience with healthcare data analysis.
- Demonstrated beginner skills with word processing and spreadsheet programs.
- Interact with others requiring the employee to communicate information.
- Operate computers and other office equipment requiring the ability to move fingers and hands.
- See and read computer monitors and documents.
- Remain sitting or standing for long periods of time to perform work on a computer, telephone, or other equipment.
- RN degree/certification.
- Certified coder and a thorough understanding of coding issues.
- Experience performing hospital bill audits on medical records or billing.
- Self motivated and able to plan work assignments and manage time effectively.
- Strong interpersonal and communication skills (both written and oral).
- Proven skills in negotiation and working in an area with a strong customer focus.
All positions subject to close without notice. Intermountain Healthcare prohibits discrimination on the basis of race, ethnicity, religion, color, national origin, sex, age, sexual orientation, gender identity/expression, veteran status, disability and/or genetic information.
Working Hours 40
Primary Work Location SelectHealth
Job Type Full Time
Location US-UT-Salt Lake City