RN CRC Coding Auditor - Remote - $10K Sign On Bonus

JOB SUMMARY

The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence-based medicine, community and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRG’s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and / or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Includes minimum education, technical training, and / or experience required to perform the job.

Education

Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment

Completion of BSN Degree Program

Experience

Three to Five years Clinical RN Experience

Experience preparing appeals for clinical denials related to DRG assignment.

CERTIFICATES, LICENSES, REGISTRATIONS

RN,

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

Benefits

Conifer offers the following benefits, subject to employment status :

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