Hospital Audit and Appeals Nurse (Hybrid)

Audit And Appeals Nurse

Your job is more than a job

Reporting to the Audit and Appeals Supervisor, the Audit and Appeals Nurse plays an important role in a high-profile group tasked with audits and appeals for all government and commercial payers due to audit request and denials. The focus is to improve revenue results by taking a global view of clinical and financial processes, functions and interdependencies from the provision of patient care to the final bill generation. Due to its service focus and project management emphasis, this position requires strong interpersonal and communication skills, well-developed analytic and organizational skills, and the ability to meet deadlines while influencing, but not directly managing the work of others.

Your Everyday

General Duties

• Manage payer denials by conducting retrospective comprehensive analytical review of clinical documentation to determine if an appeal is warranted in a timely manner
• Exercise discretion and independent judgement when completing medical record quality audits of clinical validation documentation and work prepare appeal arguments in conjunction with the appropriate department as it relates to payer policy/procedure, contract agreement and regulatory requirements.
• Research and analyze the RRL (review result letters) for government and third-party payer denials related to DRG Assignment, Medical Necessity, Level of Care, and Clinical Authorizations to send to the appropriate department; provides supporting documentation for audit and appeal in order to pursue resolution through all appeal levels, according to relevant government and third-party payer guidelines; monitor pre-billing and post billing to assist in ensuring accurate reimbursement by identifying opportunities prior to bill submission and correcting problems once the medical record has been completed.
• Follow up communication with physicians and other provider personnel to ensure documentation available supports submitted charges. Work with the Audit and Appeals coordinator to complete the appeals process.
• Collaborate with Compliance, Case Management, Coding, Patient Access, Managed Care Contracting, Central Business Office, Health Information Management, Finance, and Clinical departments to resolve Audit and Appeal trends and or other issues as identified. This includes projects related to revenue cycle initiatives.

The Must-Haves Minimum:

Experience Qualifications

• 5 to 8 years of experience Healthcare finance, revenue cycle management, patient accounting and physician billing, coding and documentation (LCMC)

Education Qualifications

• Required: Bachelor's Degree Healthcare (LCMC)

Licenses and Certifications

• Certification Name: Certified Professional Coder-Hospital
• Required
• Issuer: American Academy of Professional Coders
• Licensure Speciality: Specialty Certification
• Entity: LCMC

• Certification Name: Certified Professional Coder
• Required
• Issuer: American Academy of Professional Coders (AAPC)
• Licensure Speciality: Specialty Certification
• Entity: LCMC

• Certification Name: Certified Coding Specialist
• Required
• Issuer: Commission on Certification for Health Informatics and Information Management (CCHIIM)
• Licensure Speciality: Certification
• Entity: LCMC

• Certification Name: Certified Coding Specialist Physician-based
• Required
• Issuer: Commission on Certification for Health Informatics and Information Management (CCHIIM)
• Licensure Speciality: Certification
• Entity: LCMC

• Certification Name: Registered Nursing License
• Issuer: Louisiana State Board of Nursing
• Licensure Speciality: Licensure
• Entity: LCMC

• Certification Name: Licensed Respiratory Therapist
• Issuer: State Board of Medical Examiners
• Licensure Speciality: Licensure
• Entity: LCMC

Skills and Abilities

• Minimum Required: Knowledge of accurate sources for updating all applicable code sets (CPT/HCPCS, ICD-10, etc.) inclusive of associated edits such as NCCI. Knowledge as it relates to, but not limited to, electronic health record, health information systems and healthcare applications. Understanding of multiple reimbursement systems including IPPS, OPPS, and Managed Care. Demonstrated knowledge of computer technology and preferred knowledge of MS Office including Word, Excel, and PowerPoint. Excellent oral, written and interpersonal communication skills. Well-developed research skills and detail oriented with the ability to organize and set priorities to ensure objectives are met in a timely manner. Ability to interpret and implement regulatory standards.
• Preferred: Working knowledge regarding insurance guidelines (MA, MC, Commercial, MCO, HMO). Experience with case manager or utilization review nurse
• Electronic Health Systems Experience

Work Shift: Days (United States of America)

LCMC Health is a community. Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little "come on in" attitude is the foundation of LCMC Health's culture of everyday extraordinary

Your extras

• Deliver healthcare with heart.
• Give people a reason to smile.
• Put a little love in your work.
• Be honest and real, but with compassion.
• Bring some lagniappe into everything you do.
• Forget one-size-fits-all, think one-of-a-kind care.
• See opportunities, not problems it's all about perspective.
• Cheerlead ideas, differences, and each other.
• Love what makes you, you - because we do

You are welcome here. LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law.

The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.

Simple things make the difference.

1. To get started, take your time to fully and accurately complete the application for employment. Incomplete applications get bogged down and are often eliminated due to missing information.

2. To ensure quality care and service, we may use information on your application to verify your previous employment and background.

3. To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed.

4. To expedite the hiring process, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.