FACTORS RELATING TO JOB
Experience, Knowledge and Skill Previous Experience: A. 5 + years nursing experience of which a minimum of 5 years were clinical nursing experience. B. Minimum 2 years Utilization Management, Case Management, and/or auditing experience necessary. Specialized or Technical Education A. Registered Nurse licensed to practice in the State of Louisiana. B. Knowledge of established medical necessity criteria, InterQual and Milliman and Robertson, and their application necessary. C. Knowledge of Prospective Payment System, MS-DRG’s, APC’s, IPPS, OPPS, and other payment methodologies. D. Knowledge of ICD-9-CM coding, documentation compliance and CPT coding are required. E. Knowledge of computer systems and proficiency with Microsoft Office applications, especially Excel and Access. F. Effective verbal and written communication skills with peers, staff, legal counsel, physicians, senior management, hospital leadership, and all government regulatory and enforcement agencies (including ability to do large group presentations). G. Analytical and investigative skills necessary to identify and define issues; develop review/risk assessment plans; gather data, information, and evidence; analyze data and information; develop findings and conclusions; and make appropriate recommendations. H. Ability to lead, guide, and direct organization-wide RAC and government regulatory agency activities in documentation and billing compliance. I. Cooperative attitude in working with others to identify, analyze, and resolve problems. J. Working knowledge of rules and regulations as they pertain to CMS’ RAC program and other government regulatory and enforcement agency audits for documentation and billing compliance. K. Relates to employees and others related to North Oaks Health System on at all levels. L. Knowledge of appeals process, composition of appeal letters, and integrated follow-up. M. Computer skills necessary to maintain logs and tracking of all auditing activities.
Manual or Physical Skill Required Physical Effort Required/Physical Demands: Strength: Light Push: Occasionally Pull: Occasionally Carry: Occasionally Lift: Occasionally Sit: Frequently Stand: Frequently Walk: Frequently