Nurse Auditor, Recovery Appeals Coordinator

El Camino Health is committed to hiring, retaining and growing the best and brightest professionals who will carry our mission and vision forward. We are proud of our reputation in the community: One built on compassion, innovation, collaboration and delivering high-quality care. Come join the team that makes this happen.
Applicants MUST apply for position(s) by submitting a separate application for each individual job posting number they are interested in being considered for.
FTE
1

Scheduled Bi-Weekly Hours
80

Work Shift
Day: 8 hours

Job Description
Key Responsibilities

• Pursues, analyzes, and remains up to date on data regarding clinical/medical necessity denials.
• Collaborates with physicians, case managers, Hospital Billing Office staff and payers to prevent and appeal clinical denials.
• Ensures a functional denial appeals process, including measuring clinical denial and appeal activity, monitoring patterns and trends, and reporting the outcomes of these activities as requested.
• Serves as the central point person for commercial and government claim recovery activities providing efficient management of workflow related to Medicare, commercial insurance clinical denial/appeal and Recovery Audit Contractor activities.
• Provides guidance, support and oversight to ensure effective management of the audit response process.
• Facilitates all aspects of the clinical denial/appeal process which include tracking and trending denials, performance improvement and reporting process outcomes.
• Collaborates with clinical and finance/revenue cycle departments to ensure the integrity of charges captured, as well as compliance with government, payer, and internal charge capture audit policies.
• This position coordinates with Care Coordination utilization review staff, department managers, and Revenue Cycle staff to validate proper clinical documentation of services that have been charged.
• Understands the comprehensive revenue cycle and the role of each key stakeholder, including but not limited to Patient Access, Clinical Departments/Charge Capture, Revenue Integrity/Charge Description Master (CDM), Managed Care Contracting Services, Health Information Management Services (HIMS), and Patient Accounts.

Qualifications

• Five (5) years' experience in hospital denials/appeals, case management, or clinical documentation improvement.
• Three (3) years' experience working as a Nurse Auditor or Revenue Integrity-related position in an acute hospital.
• In-depth knowledge of CMS regulations/guidance related to hospital billing and documentation requirements.
• Solid grasp of hospital's comprehensive revenue cycle.
• Thorough familiarity with hospital billing key claim elements (i.e. UB-04, CPT/HCPCS, ICD-10 codes).
• Experience with program development and strong working knowledge of federal government regulations with specific focus on Medicare reimbursement.
• Familiar with reviewing procedural documentation areas in electronic health record.
• Highly collaborative and able to work cohesively in a dynamic team environment; strong interpersonal and professional skills.
• Strong data processing and analytical skills, accompanied by strong critical thinking skills and an aptitude for conducting thorough research.

License/Certification/Registration Requirements
Current registration in the State of California as a Registered Nurse

Ages of Patients Served
N/A

Salary Range
$ $127.95 USD Hourly

The Physical Requirements and Working Conditions of this job are available. El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.
Sedentary Work - Duties performed mostly while sitting; walking and standing at times. Occasionally lift or carry up to 10 lbs. Uses hands and fingers. - (Physical Requirements-United States of America)

An Equal Opportunity Employer
El Camino Health seeks and values a diverse workforce. The organization is an equal opportunity employer and makes employment decisions on the basis of qualifications and competencies. El Camino Health prohibits discrimination in employment based on race, ancestry, national origin, color, sex, sexual orientation, gender identity, religion, disability, marital status, age, medical condition or any other status protected by law. In addition to state and federal law, El Camino Health also follows all applicable fair and equitable employment policies from the County of Santa Clara.