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The Revenue Cycle Clinical Nurse Auditor leverages clinical knowledge and documentation review to ensure appropriate charge capture and revenue optimization. Responsibilities include leveraging Epic technology and analytics to identify revenue integrity trends and investigate areas of revenue leakage, monitor financial performance and work with IT to build mistake-proofing into the Epic system. The nurse auditor will work with clinical teams, compliance and other departments within revenue cycle to provide documentation and charging education and maximize system efficiency, timely and complete charge capture, and submission of clean claims to payer to drive financial performance.
Reports to
Vice President, Revenue Cycle
Job Specific Responsibilities
1. Responsible for identifying, building, and maintaining revenue guardian edits within the Epic billing system based on documentation and CDM requirements.
2. Perform routine chart audits and clinical documentation review to identify correct level of care, missing, incorrect or undocumented charges across clinic, hospital and ancillary departments.
3. Provide education to clinical and professional staff regarding proper documentation to ensure accurate patient charging.
4. Work with clinical, financial, and operational stakeholders to implement accurate and complete charging for new and emerging therapies and services and high-risk/high-dollar services provided by the organization.
5. Facilitate the review and response to CMS Medicare RAC Audits along with other payer and outside agency audits involving hospital billing.
6. Finalize and sign-off with those auditors on agreed upon final audit reports and charges.
7. Utilize clinical knowledge and documentation review to identify revenue guardian edits within the billing system and perform routine chart audits.
8. Collaborate with clinical teams and other departments to provide documentation and charging education, maximize system efficiency, and ensure timely and complete charge capture.
9. Monitor KPIs such as missing and late charges, charge lag timeframes, average daily revenue, ABN completion, DNFB days/days to timely bill, and clinically triggered charges. Also, follow up on improvement initiatives with departments negatively impacting metrics.
10. Monitor denial trends related to upstream system and logic issues and/or workflows and act as a liaison across departments to find solutions.
11. Align with CDI, Coding and CBO/Revenue Cycle follow-ups teams to reduce denials and influence proactive revenue optimization.
12. Work effectively with ancillary departments, IT, physicians, clinics, and all other hospital clinical areas to resolve charge capture and process gaps.
13. Develop and update policies related to billing and revenue and perform clinical investigations of potential claim payment integrity issues.
14. The nurse auditor will facilitate drafting appeal letters and identify denial trend root causes.
Education and Experience
• Bachelor’s degree in nursing from an accredited college or university
• 5+ years of experience in utilization review, clinical review, and authorizations
• Knowledge of CMS Medicare Part A, B, & C billing requirements
• Advanced experience with national evidence-based screening guidelines (MCG, formerly Milliman Care Guidelines)
• Viseo software experienced user, is preferred
Required Licensures/Certifications/Registrations
• Valid Texas RN License/Eligible Compact License
Knowledge, Skills and Abilities
• Well-versed in ICD10 diagnosis codes and payer regulations
• Expert level analytical and process mapping skills
• High level knowledge of Medicare, managed care, and commercial insurance payment requirements
• Excellent attention to detail, communication and reporting skills
• Highly organized with the ability to multi-task and prioritize work
• Self-starter with the ability to think outside-the-box to solve problems
• Customer service focus, critical thinker, and excellent interpersonal skills
Interaction with Other Departments and Other Relationships
Collaborate with colleagues in patient financial services, practice management, and other relevant departments. Communicate effectively with team members and supervisors.
Physical Capabilities
Occasionally exerts a small amount of force to lift, carry, push, pull, and move objects. Employees should be able to lift 10 lbs. Work involves sitting for prolonged periods of time. Hearing acuity is required to be able to accurately transact business dealings.
Environmental/Working Conditions
This position is subject to indoor environmental conditions. Protection from weather conditions is present, however, temperature changes inside the building may occur. This position may travel to off-site locations; therefore, participation in certain activities will be based on present weather conditions.
Direct Reports
N/A
UMC Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
*Request for accommodations in the hire process should be directed to UMC Human Resources.*