PRN RN Utilization Review Audit Specialist

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General Summary

Under general supervision, conducts internal audits of hospital bills working with external auditors to ensure that uncompensated patient revenues resulting from audits of patient service billings (claims) are minimal. Use the information obtained from the audit process to inform and educate UMMS personnel concerning clinical reimbursement results and practices.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

All registered nurses working within UMMS shall follow the guidelines for professional practice promulgated by the Maryland State Board of Nursing. Any need for interpretation of the guidelines will be the responsibility of the UMMS Vice President or his/her designee.

1. Plans work for self and with coworkers, including setting goals, prioritizing work and coordinating the execution of work. Determines work priorities and resource allocation across multiple clinical audit activities based on interpretation of data and reports.

A. Uses a systematic process to identify departmental charges.

B. Evaluates each patient medical record reviewing specific documents relating to patient treatment and billable charges, identifying services billed versus services rendered.

C. Evaluates patient medical record versus the bill, noting discrepancies in over-, under- and incorrectly billed items, correctly calculates the total dollar amounts for each discrepancy and submits necessary documents for patient account adjustment.

D. Negotiates with external auditors regarding billing issues.

E. Completes and submits audit documentation in a timely fashion.

F. Communicates regularly with UMMS clinical and administrative personnel to obtain further supportive documentation for billed services beyond that which is found in the medical record.

G. Audits predetermined amount of billing based on complexity of audit.

H. Meets with appropriate department personnel to establish methods for obtaining support documentation.

2. Gathers and records data used for individual, team, and feedback performance reporting. Responsible for the integrity of recorded information.

3. Communicates with representatives of external audit companies, insurance companies, UMMS personnel, and regulatory agencies to ensure congruence with and understanding of UMMS’ audit policy, process, practice and standards.

4. Provides concurrent review of charge capture prior to claim submission in order to maximize reimbursement and reduce revenue loss through audit process.

5. Works with the Director in the identification and research of denials received for lack of authorization and for lack of medical acuity continued stay and coordinates drafting of the facility’s appeal responses.

A. Assists Patient Financial Services to determine the nature of the denial for cases rejected for payment by third payor; assesses feasibility of appeal applying Interqual criteria and M&R criteria for length of stay.

B. Researches medical records on referred claim rejection cases and denials for which letters were received directly by Clinical Reimbursement utilizing criteria sets. Ascertains the prospective appeal for the days denied by the third-party payer.

C. Identifies cases in which an appeal is to be generated, coordinates appeal process with the physician and healthcare staff following departmental procedures. Documentation of activity in appeals process is documented in MIDAS following departmental procedures.

D. Receives notification from third party payer; seeks additional information to be used for appeal letters from case management staff and what information documented in the MIDAS software on the concurrent review process.

E. Develops a working relationship with the nurse reviewers coming onsite from the larger local payers fostering improved communication. Tracks approved and potentially deniable days on all respective members at discharge.

F. Obtains information to aid the onsite reviewers in completing chart review post discharge when necessary. Uses onsite reviewers as a mediator in resolving particular issues with claim resolution within their system.

G. Assists the Director in collection of data on denials and the retrieval of reports on denied days received by the facility, identifies trends, tracks appeal success, and provides and interprets reports of denied days statistics from denials received to Case Management, Finance, and other hospital departments as requested.

6. Gives feedback to other departments.

A. Meets with appropriate department and supervisory personnel to share information obtained during the audit process to assist in the identification of problems that result in a loss of revenue.

B. Shares clinical expertise and knowledge with the Department of Patient Financial Services personnel to assist in the negotiations and resolution of patient and insurance company inquires.

C. Participates in patient unit and UMMS educational programs to address identified issues.

7. Improves work processes in an active and continuous manner. Uses improvement tools and methods to improve individual, team and cross-departmental performance. Bases improvements on customer requirements, data, root-cause analysis and outcomes.

8. Keeps current on clinical practice and protocols that impact the patient claim audit process to include insurance regulations, Medical System charging practices and clinical therapy updates through communication with supervisor, appropriate professional publications and conferences.

9. Communicates effectively with immediate supervisor. Provides information regarding work progress, actions and issues in a timely manner.

10. Designs and implements special audit and education projects

Education and Experience

1. Current active RN registration with the Maryland State Board of Nursing is required.

2. Four years professional nursing experience, with experience in a patient care setting and two years performing Utilization Review/Quality Assurance/Case Management responsibilities.

Knowledge, Skills and Abilities

1. Knowledge of hospital review procedures, third party payment, quality improvement and regulatory agency procedures and policies.

2. Effective oral and written communication skills required to deal with insurance companies and hospital staff.

3. Effective negotiating skills.

4. Ability to apply clinical assessment skills to the medical record audit process and extract supportive documentation.

5. Ability to apply patient care protocols (standardized; UMMS; TJC) to billing practices.

6. Demonstrated ability in use of personal computer and related software. Expertise in spreadsheets, word processing and data base management packages preferred; ability to learn these skills required.

7. Ability to work independently.

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