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Job Category:




Approximate Salary:

Not Specified

Position Type:

Full Time

RN Auditor - Hospital Revenue Integrity – Telecommute


Posted: 12/10/2018

Under the direction of the Revenue Integrity Director, the Nurse Auditor will perform charge audits, patient appeals, grievances and reconsideration for denied payments.  This position will work closely with various departments to verify services provided, clinical documentation, and charge capture is in alignment.  This position will communicate all audit findings with the necessary parties and work closely with external auditors to obtain resolution of disputes.  Types of audits include: Managed Care Defense, Patient Requests, Outlier Audits for Medicaid and various senior plans and other special request audits.
You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
  • Performs Defense Audits on paid Managed Care accounts that an external auditor has identified discrepancies. Audits are performed on charges originally billed to a payer against the necessary clinical documentation to identify any possible over and under charges.  Audit results are documented and sent to external auditors for review and resolution in a timely manner.  Auditors will continue communication until all discrepancies are resolved
  • Performs charge audits requested by a patient.  If a patient is disputing charges, the Clinical Auditor will review the billed charges against all necessary clinical documentation for any discrepancies in a timely manner.  All audit results are documented, posted to the account, and communicated to the necessary parties
  • Performs audits for Government accounts that have not paid according to their contractual agreement due to denied charges.  All charges are audited against necessary clinical information to both validate the denial, and identify any possible charge discrepancies.  Audit finding are documented, posted to the account, and sent to the appropriate units for rebilling if necessary
  • Performs facility clinical documentation audits.  Clinical documentation is audited against the charges captured to identify deficiencies in documentation or missing charges.  May provide educational services to clients based on audits results
  • Adheres to department time goals for each type of audit or tasked performed
  • Educates others on guidelines, criteria, regulations  and procedures
  • Charge reconciliation is required for all audits performed to ensure all over and under charges have been posted to the account and adjusted bills have been produced.  If needed, works with the posting unit for any issues identified in the reconciliation/posting process
  • Works with various departments to obtain the necessary information to perform account audits. This includes, but is not limited to, Health Information Management department, Clinical units, Case Managers, and Physicians 
  • Leverage technology including on-line applications and internal programs to research information and complete audits efficiently. As well as understanding the workflow of the healthcare delivery system
  • Responsible for documenting all audit findings in both the Financial System and internal audit logs. Maintains all clinical audit reports and weekly production reports
  • Maintains daily productivity report indicating hours worked on audit and non -audit tasks.
  • Reports any reoccurring charging issues that are identified to Management
  • Maintains current working knowledge of ICD and CPT coding principals, government regulations and protocols

Required Qualifications:
  • Current, unrestricted RN license
  • Knowledge of hospital billing and charging processes
  • 3 - 5 years charge audit or hospital appeals  experience
  • Understanding of Medical Terminology
  • Understanding of the rules and guidelines to include American Association of Medical Audit Specialists (AAMAS), and National Commission on Insurance Guidelines and Medicare billing guidelines (CMS)
  • Proficiency with Microsoft Word and Excel
Preferred Qualifications:
  • Experience with Cerner clinical applications
  • Coding certification to include the following: CPC, CCS, RHIA, and RHIT
  • ICD-10 knowledge
  • Experience with Insurance denials and contracts

    Optum360 is a dynamic partnership formed by Dignity Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage all our resources to bring financial clarity and a full suite of revenue management services to health care providers nationwide.

    If you're looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm)
    *All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy

    Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
    UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
    Job Keyword: RN Auditor, RN, Revenue Integrity RN, Appeals RN, Charge Auditor, telecommute, CPC, CCS, RHIA, and RHIT

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