RN CRC Coding Auditor - Remote

RN CRC Coding Auditor - REMOTE - $10K Sign On Bonus

The CRC Auditor conducts coding and documentation quality reviews and generates responses for cases denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims are coded and billed in accordance with nationally recognized coding guidelines, standards, regulations, and regulatory requirements, as well as payor and billing guidelines. Responses may include system documentation of findings and/or a formal appeal letter.

The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor will perform analysis on clinical documentation, evidence-based criteria application outcomes, physician documentation, and physician advisor input, and will complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to CRC leadership. Provides expert application of evidence-based medical necessity review criteria tools. Works collaboratively to review, evaluate and improve the denial appeal process.

• Formulates and submits letters of appeal. Creates effective appeals utilizing relevant clinical documentation from the medical record, supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, and applicable standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in the appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, per-diems, DRG’s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

• Effectively organizes work priorities
• Demonstrates compliance with departmental safety and security policies and practices
• Demonstrates critical thinking, analytical skills, and problem-solving abilities
• Ability to handle multiple assignments and work independently with minimal supervision
• Maintains accuracy at unit standard KPI goals
• Excellent written and verbal communication skills
• Detail oriented with ability to work independently and in a team
• Moderate skills in MS Excel, PowerPoint, and MS Office
• Ability to research difficult coding and documentation issues and follow through to resolution
• Ability to work in a virtual setting under minimal supervision
• Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to start of employment. This may include COVID-19 vaccination, influenza vaccination, and/or other required vaccines.

• Minimum
  
  Required:
  • Completion of BSN Degree Program or three years of experience with completion of BSN within five years of employment
  • RN License in the state of practice
  • Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement
• Preferred/Desired:
  • Completion of BSN Degree Program
  • CCDS certification or inpatient coding certification

• Minimum
  
  Required:
  • Three to five years clinical RN experience
  • Three to five years of Clinical Documentation Integrity experience
  • Expertise with Inter Qual and/or MCG Disease Management ideologies
  • Strong communication and interpersonal skills
  • Knowledge of CMS regulations
  • Knowledge of inpatient coding guidelines
  • 1–2 years of current experience with reimbursement methodologies
• Preferred/Desired:
  • Experience preparing appeals for…