POSITION SUMMARY
This position is responsible for performing government and private payer audit reviews and appeals. This position also acts as a resource for clinical issues that arise in the Billing Office and other members of the bill review team. Other responsibilities include, but are not limited to, completing clinical reviews for medical necessity and applying InterQual level of care criteria, contacting providers to resolve billing issues, and assisting with resolution of patient disputes regarding charges. This position primarily functions in an office setting, with occasional work on the nursing units involving possible exposure communicable disease and body fluids. Majority of time is spent sitting (up to 60% of work time) with frequent standing and walking of short distances required (up to 40% of work time.) This position is frequently required to lift and carry objects weighing up to 10 lb. (up to 20% of work time.)
LICENSES/CERTIFICATIONS REQUIRED Arkansas RN License
DESCRIBE THE SPECIFIC EDUCATIONAL AND SKILL COMPETENCIES REQUIRED FOR THIS POSITION.
A minimum of one year nurse auditor experience or Case Management Certification (CCM) required. Advanced degree with training or experience in auditing of clinical records preferred. A minimum of three years nursing experience required. This position requires good knowledge of government payer guidelines, third party administrators, appeals, and claims. Knowledge of coding and billing required. Good clinical knowledge needed to effectively interact with all levels of health care providers. Good written and verbal communication skills a must. Proficiency with Microsoft Office products required. Knowledge of "severity of illness" and "intensity of service" criteria (i.e., InterQual) required. Charge master work experience a plus.
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