NURSE AUDITOR - ACCURATE PROVIDER PAYMENT UNIT - REMOTE ELIGIBLE Job in Albuquerque, New Mexico

This opportunity is open to remote applicants in the United States, with the exception of the following states:

Washington, Wyoming, North Dakota, and Ohio.

MUST HAVE A COMPACT NURSING LICENSE OR WILLING TO REGISTER IN NM

Summary:
As part of the Accurate Provider Payment Unit (APPU), the Nurse Auditor conducts high dollar retrospective or prospective reviews of hospital facility claims. The Nurse Auditor is responsible for conducting line item audits of facility claims against itemizations and medical records to ensure services billed were rendered and documented and that services were not unbundled and were appropriately billed

Requirements:

*Requires experience in the principles of medical coding including the applicability and interpretation of ICD-10CM diagnosis coding, CPT and HCPCS Level II Coding.

*RN-NM

*Candidates who are selected for the position must have a CPC credential at the time of hire or sign an agreement to obtain this credential within six months of hire.
*Experience in conducting medical chart reviews and audits, along with medical claims knowledge.
*Proficient in Microsoft word and excel.
*Health Plan Experience is preferred.

Responsibilities:

*Requests medical records and itemizations from hospital facilities in order to validate high dollar retrospective or prospective claims.
*Claim audits are prioritized and conducted in the order that meets the contractual agreements and financial goals of the health plan.
*Receives, reviews, verifies, and processes requests for chart audits of inpatient hospitalizations.
*Conducts reviews of facilities and completes all documentation accurately and appropriately and enters outcome data into case management tracking system (i-Sight) and the internal claims systems utilized by the health plan (Facets & HRP).
*Interacts with Medical Director to obtain advisement on medical issues and concerns.
*Monitors the claims review queue and makes certain reviews are conducted in a timely and accurate manner.
*Collaborates with Provider Network Operations, Claims, Finance, Health Services, and other department staff on the outcomes of the review findings and assists Provider Network Operations with educational efforts.
*Provides feedback and process improvement recommendations to appropriate health plan Quality, Health Services, Provider Network Operations, Finance, Claims Recovery, Legal/Compliance departments and committees based on analysis and trending of hospital reviews.
*Maintains up-to-date information, which is reported to regulatory agencies (e.g., State of New Mexico Human Services Department)
*Advises Director of Program Integrity of possible trends in inappropriate utilization (under and/or over), and other potential concerns, to include quality of care issues.
*Performs other functions as required