Clinical Auditor Manager
2 weeks ago
About the Role:
SSM Health is seeking a highly skilled Clinical Auditor Manager to join our Care Transformation team. As a key member of our team, 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:
- Develop and maintain auditing tools, procedures, and reporting for all areas of Care Transformation operations.
- Perform operational and compliance audits adhering to regulatory requirements.
- Create and standardize policies, procedures, and reporting for all auditing procedures.
- Review patient medical record documentation related to Clinical Documentation Improvement, Utilization Management, and compare against medical bills, claims, and revenue reports.
- Participate in training of specific areas of focus by tailoring to specific needs identified within auditing findings.
- Utilize auditing data, along with data analysts/liaisons, to improve risk adjustment measures and denial management processes within the department.
- Resolve inquiries from internal and external sources to reconcile accounts accurately and within compliance guidelines.
- Ensure compliance with government and billing guidelines by reviewing and splitting or combining claims per clinical/billing guidelines.
- Enhance net revenue by splitting charges that should be presented on separate claims to capture entitled revenue.
- Improve claim submissions by reviewing, researching, resolving, and trending claim issues in a timely manner.
Requirements:
- Graduate of an accredited school of nursing or education equivalency for licensing.
- 7 years of relevant experience in clinical auditing.
Professional Licenses and Certifications:
- 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.
Work Environment:
SSM Health is an equal opportunity employer. We value diversity and inclusion and are committed to creating a workplace that is welcoming and inclusive for all employees.
Benefits:
- Paid Parental Leave.
- Flexible Payment Options.
- Upfront Tuition Coverage.
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