Nurse Auditor

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary
Functions as Hospital Liaison with Third Party billing and auditing firms for all audits for LVHN locations. Reviews all audits in LVHN audit software and writes appeals for charge and line item audit denials as well as level of care and medical necessity denials. Communicates audit results and develops action plan to reduce incidence of denials for LVHN. Provides explanation of hospital charges to inquiring patients. Participates in revenue recovery/revenue enhancement through the verification of correct charging procedures in EMR. Provides education to hospital departments to facilitate correct charges on all claims. Works with Physician Advisors on appeals to payors/third party vendor and documents their follow up in LVHN audit software and EMR. Collaborates with management team to participate with Insurance providers and third-party audit vendors to resolve audit appeal disputes or issues.

Job Duties

• Creates an audit appeal letter to uphold the claim based on our charging practices or medical necessity documentation found in the EMR or coordinates and implements on site audits as required in lieu of a written appeal.
• Coordinates audit appeals that need a physician’s input with the payor and sends claims to write off that have no further appeals. Coordinates downgrade of class as directed by Physician Advisor for audited claims.
• Facilitates write off accounts that cannot provide support for line item denials or level of care denials.
• Looks for missing charges and investigates charges and usage to be sure correct charges are on the claim.
• Identifies areas of incorrect charging practice, provides action plan to correct charging and does follow up auditing for compliance of action plan.
• Provides monthly reporting, while working with clinical data support team, for action plans, line item audits and medical necessity audits.
• Keeps all assigned work ques current that includes but are not limited to Gift of Life, Life threatening, OBV hours, bed charges.
• Ensures compliance with regulatory and accrediting requirements.
• Charge corrections and conversion accounts will be worked by this group.
• Will complete special projects as assigned.

Minimum Qualifications

• Specialized Diploma in nursing
• 10 years clinical experience
• Ability to read medical charts and identify deficiencies in documentation content.
• Ability to adapt to ongoing changes within the health insurance industry in order to effectively implement positive changes.
• Knowledge of medical policy per payor guidelines. Knowledge of Auth/Cert and utilization review and hospital departmental procedures.
• Knowledge of where to look for coding of claims and interact with HIM when needed,
• Insurance knowledge of payor process and payment/audit rules.
• Knowledge of Epic workflows with notes in account history and WQ Workflows.
• Knowledge of hospital based charging methods such as charge tables, medical records and billing formats.
• Intermediate knowledge of Excel and MS Word.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire

Preferred Qualifications

• Bachelor’s Degree in nursing

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

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Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

Work Shift:

Day Shift

Address:

1200 S Cedar Crest Blvd

Primary Location:

REMOTE IN PENNSYLVANIA

Position Type:

Remote

Union:

Not Applicable

Work Schedule:

Monday-Friday; 8:00a-4:30p

Department:

1004-13060 CSS-Clinical Appeals - Denial Mgmt