Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.
The Clinical Nurse Auditor Reviews and evaluates medical records, clinical documentation, charge coding, and healthcare billing for accuracy, compliance and quality. Responsible for the identification, mitigation, and prevention of clinical denials. Works to prevent future clinical denials by communicating with clinical and revenue cycle leadership about denial root causes, such as documentation gaps or insufficient charge capture, and helps develop and implement staff education and process changes.
Required Behaviors:
- As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications:
- Registered nurse (RN) licensure
- At least three years of experience required in one of the following areas: clinical documentation, case management, denials, billing
- Familiarity with National Coverage Determinations and Local Coverage Determinations
- Proficient in medical terminology and able to interpret patient medical records
- Knowledge of medical necessity screening criteria (e.g., Milliman, InterQual)
- Proficient in EHR and other systems used by organization
- Strong time management and prioritization skills
- Excellent communication and customer service with patients and staff
- Strong attention to detail
Preferred Qualifications:
- Bachelor’s degree in nursing
- Certification in at least one of the following: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare management), certified case manager, certified documentation specialist, certified coder, certified professional medical auditor, or similar program
- Previous experience working as an RN
Duties and Responsibilities:
- Reconciles charges against clinical source documentation to ensure that charges have been captured completely and accurately and identify discrepancies between documentation and billed services.
- Reviews patient medical records for accuracy, completeness, and compliance with documentation standards.
- Identifies gaps in clinical documentation and charge capture and works with clinical staff to develop and implement quality improvement and staff education initiatives.
- Conducts internal audits of clinical records and billing charge codes to identify process gaps and resolve errors.
- Prepares audit reports and summaries with findings, recommendations, and corrective action for quality improvement opportunities for revenue integrity leadership.
- Monitors health system compliance with hospital, state, and insurance regulations.
- Reviews payor contracts to understand and educate staff on best practice clinical documentation and charging practices and, when necessary, coordinates with Contract Management Specialists in payor contract updates.
- Collaborates with coding teams, billing departments, quality assurance personnel, and clinical staff to promote accurate and timely charge capture.
- Provides clinical expertise and assistance with claim denial resolution.
- Assesses the quality of charge capture and coding as they relate to clinical denials across SJRMC departments.
- Advises revenue cycle leadership, department leaders and their staff on proper usage of charge codes.
- Provides departmental charge education and training to staff engaged in charge data entry and related charge capture/reconciliation activities to ensure procedures are understood and charges are booked timely, appropriately, accurately, and completely, and are properly documented.
- Assists in identification and resolution of accounts held in A/R due to charging and clinical documentation discrepancies.
- Facilitates communication with care providers regarding documentation opportunities and/or requirements.
- Maintains knowledge of and adherence to code of conduct standards, confidentiality agreements, and San Juan Regional Medical Center’s mission statement.
- Each caregiver is responsible for implementing SJRMC’s Service Standards into their daily work: Safety, Courtesy, Effectiveness, and Stewardship
- Other duties as assigned
Physical Demands and Environmental Work Conditions:
- Prolonged standing/sitting/walking
- Fast paced environment
- High level of activity with many interruptions
- Possible exposure to communicable disease
- Repetitive motions (i.e., keyboard usage)
Sensory requirements:
The employee will need to be able to hear:
- Alarms on equipment/fire alarms/overhead announcements
- Patients/family/physician verbal discussion
- Feedback from other healthcare providers
The employee will need to be able to:
- See and focus on close-up and distant objects
- Have intact: peripheral vision and depth perception