Regulatory Review Program RN

4 weeks ago

San Francisco, California, United States CommonSpirit Health Full time

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Responsibilities

This is a remote position

The CommonSpirit Regulatory Review Program (RRP) RN supports the regulatory requirements of Care Coordination activities in partnership with Revenue Cycle, Compliance, and other applicable stakeholders. This position is responsible and accountable for the auditing of patient records to identify areas of risk in order to ensure conformance with System policies and regulatory requirements, compliance to accurate medical necessity reviews, and support proper claim submission.

This position will complete scheduled, system-wide regulatory and compliance Care Coordination audits in order to achieve organizational objectives by using a systematic approach to evaluate and improve the effectiveness of risk management and quality control by completing audits, analyzing and preparing findings for further management analysis and review. This position is also responsible for case review and research in order to support a compliant and accurate claim submission process, reduce costly delays in payment, and maximize claims reimbursement. Incumbents will use professional judgment, independent analysis and critical-thinking skills to apply clinical guidelines, policies, and regulatory requirements to ensure appropriate, complete medical necessity review, claim billing status, and discharge planning requirements.

Essential Key Job Responsibilities

  • Applies knowledge of Medicare rules and regulations pertaining to compliant billing of Medicare accounts.
  • ADT status determination utilizing screening tool guidelines and Intensity of Service/ Severity of Illness criteria, and completion of thorough and accurate clinical chart review.
  • Conduct and complete Care Coordination regulatory and compliance audits.
  • Analysis and reporting of audit findings to RRP Leadership
  • Identifies potential compliance issues that require resolution prior to release for billing.
  • Data collection and analysis for the purpose of identifying and tracking specific trends.
  • Facilitate second level physician reviews for appropriate level of care determination.
  • Documents in the electronic medical record.
  • Communicate/escalate issues to appropriate stakeholders.
  • Communicate appropriate level of care and release for billing.
  • Cross-train to the different job functions within the department.
  • Assist with new RRP RN orientation and training.
  • Perform other duties as assigned by the manager including reports, PowerPoints, and in-depth case research.

Qualifications

Required Experience, Education and License/Certifications

  • Bachelor's degree required
  • 5 years of general bedside acute care experience required
  • Master's degree (MSN, MBA, MPH, MHA, APN) preferred
  • Care Coordination experience and/or Utilization Management preferred
  • Regulatory Compliance experience preferred
  • Audit / analyst experience preferred
  • Minimum two (2) years' experience with denial management, claims review, clinical documentation integrity or similar role preferred.
  • Familiarity with Cerner or Epic and Midas
  • Working knowledge of screening guidelines (IQ & MCG)
  • Current RN License
  • CCM or ACM, or applicable certification (preferred)
  • Equivalent combination of education and experience may be considered

Pay Range

$ $68.30 /hour

We are an equal opportunity/affirmative action employer.


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