The Clinical Nurse Auditor performs concurrent reviews of all inpatients with Florida Medicaid and submitting authorization requests for admission/continued stay to eQ Health. This position requires critical thinking and judgment and must demonstrate the ability to appropriately use standard criteria such as Interqual and Milliman in addition to criteria established by state Medicaid programs or hospital policy. Audit and analysis must be accurate and consistently ensure a high level of quality, knowledge of laws, rules, regulations and guidelines necessary to ensure compliance and protection of information
Primary / Essential Functions:
The Primary/ essential job duties may not be exhaustive.
Performs audits of medical records to identify and/or defend charges, including:
Patient inquiry audits
Participates as needed on hospital-based committees and/or meetings
Joint Operating Committees
Completes analysis of records against established criteria, i.e., Interqual, Medicaid criteria, to determine if patient condition and/or care meets that criteria, including:
Avoidable day studies
Managed care or Medicaid reconsiderations/appeals
Proficiently utilize multiple computer-based systems to complete and document work
Client-based billing, medical record and quality systems
Microsoft Outlook, Word, Excel
Physical / Mental Demands, Environment:
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, recognizing that Adreima must work within the limitations established by the client when working on-site.
Must be able to use hands to finger, handle or feel, sit, stand, walk, lift up to 20 pounds, stoop, clean, bend, and reach with hands and arms.
Must communicate clearly in English. Requires the ability to speak, read, write, see, and hear to perform essential duties of the job.
Effective and positive human relations skills are required, including confidentiality, in order to appropriately interface with staff, patients and their families.
Must be able to perform multiple tasks and detailed work, problem solve, reason, and perform basic mathematical calculations.
Telephone, FAX machine, calculator/adding machine, computer, monitor, printer, hardware and software packages, computer peripheral equipment i.e. mouse and keyboard; and Microsoft software.
Must be a Registered Nurse
Two or more years of experience reviewing medical records in a hospital or payor environment
Recent clinical experience, preferably in multiple clinical arenas
Able to communicate clearly, both verbally and in writing.
Utilizes a variety of strategies or approaches to communicate effectively with others
Able to explain priorities effectively
Adreima - 2 years ago
Adreima specializes in assisting hospitals maximize reimbursements while decreasing demands on in-house staff. Our Receivables Management...