The Clinical Auditor role is responsible for documenting areas of risk within the revenue cycle. Core operation is to discover opportunities post billing that will allow for appeals, system updates and process changes to prevent future losses/misses.

SCP Health Core Values: Agility, Respect, Courage, and Collaboration

JOB PROFILE SUMMARY: This role is responsible for documenting areas of risk within the revenue cycle. Core operation is to discover opportunities post billing that will allow for appeals, system updates and process changes to prevent future losses/misses.

SCP Health Core Values: Agility, Respect, Courage, and Collaboration

Core Values:

In alignment with the core values of SCP Health, the Clinical Auditor role aligns with the organization’s core values by:

Agility: Possess the ability to adeptly prioritize and perform multiple duties concurrently. The Clinical Auditor must be able to assess the needs of the department and organization and quickly make decisions to further advance the business.

Respect: The Clinical Auditor will demonstrate a professional mannerism with all verbal and written communications as well as any other department interactions. Auditor will adhere to RCS & SCP HR policies and practices.

Courage: The Clinical Auditor will be self-motivated, have a willingness to take initiatives, and exhibit the ability to respond to and provide feedback for job duties.

Collaboration: Work with business partners, both within the department and company to ensure a healthy organization and promote the culture of SCP Health. The Coding/Revenue Integrity Auditor must also be able to work closely with individuals outside of the organization daily.

JOB DESCRIPTION:

Responsibilities:

• Provide expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances
• Analyze and identify trends for appeals and grievances
• Communicates with appropriate parties any and all issues, implications and decisions
• Collaborate with billing companies to provide feedback related to improvement opportunities and appeal campaigns
• Respect company policies and procedures to ensure they are current and accurately reflect processes in order to comply with regulatory requirements.
• Agility in managing workflow to meet timely filing deadlines and production management
• Liaison to billing companies, payers and other necessary parties; responsible for validating appeal process as well and the correction of discoveries
• Maintain thorough knowledge of CMS reimbursement regulations related to assigned region
• Promotes compliance with and adheres to all regulatory and quality standards including but not limited to: Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and accreditation bodies' standards such as the National Committee for Quality Assurance (NCQA) as it relates to the Grievance and Appeal Department activities
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.

Knowledge, Skills, and Abilities:

• Knowledge of Emergency Department and Hospital Medicine coding guidelines.
• Knowledge of Centers for Medicare and Medicaid Services (CMS) coding and billing requirements.
• Significant skills in business applications:
  • Excel, Word, PowerPoint
• Must be well organized and demonstrate effective time management skills.

EDUCATION:

• RN, LPN or RHIA license preferred
• BS or BA degree in healthcare or management field preferred

FIELD OF STUDY:

• Nursing, professional coding, or healthcare related work experience

WORK EXPERIENCE/QUALIFICATIONS:

• 3-5 years healthcare reimbursement experience
• 3-5 years coding or nursing experience

CERTIFICATES AND LICENSES:

• RN, LPN or RHIA license preferred

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

• Professional setting
• Continuous sitting
• Continuous oral & written communication and listening skills
• Continuous computer use
• Occasional bending, kneeling, lifting, pulling & pushing up to 10 pounds
• Job requires a high level of mental awareness