Clinical Auditor Manager
6 days ago
As a Clinical Auditor Manager at SSM Health, you will be responsible for ensuring the daily management of auditing, monitoring of processes, reporting, and outcomes to ensure Care Transformation is compliant with regulatory requirements and standards are maintained.
Key Responsibilities- Creates and maintains auditing tools, procedures, and reporting for all areas of Care Transformation operations: Clinical Documentation Improvement; Utilization Management and Status Review; Case Management Standard Work.
- Performs operational and compliance audits adhering to regulatory requirements.
- Creates and standardizes policies, procedures, and reporting for all auditing procedures.
- Reviews patient medical record documentation related to Clinical Documentation Improvement, Utilization Management, and compares against medical bills, claims, and revenue reports.
- Participates in training of specific area of focus by tailoring to specific needs identified within auditing findings.
- Utilizes auditing data, along with data analysts/liaisons, to improve risk adjustment measures and denial management processes within department.
- Resolves inquiries from internal and external sources to reconcile accounts accurately and within compliance guidelines.
- Ensures compliance with government and billing guidelines by reviewing and splitting or combining claims per clinical/billing guidelines. Enhances net revenue by splitting charges that should be presented on separate claims to capture entitled revenue.
- Improves claim submissions by reviewing, researching, resolving, and trending claim issues in a timely manner.
- Graduate of accredited school of nursing or education equivalency for licensing.
- 7 year's relevant experience in clinical auditing.
- Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR).
- Registered Nurse (RN) Issued by Compact State.
- Registered Nurse (RN) - Missouri Division of Professional Registration.
- Registered Nurse (RN) - Oklahoma Board of Nursing (OBN).
- Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services.
Day Shift (United States of America).
BenefitsSSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.
- Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
- Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply).
- Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.
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