RN Patient Billing Documentation Auditor

Metro Health | Wyoming, MI

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Posted Date 1/11/2019

RN Patient Billing Documentation Auditor - Patient Audit * Days - 16hrs/wk.

Requisition #: req948

Shift: Days

FTE status: 0.4

On-call: No

Weekends: No

General Summary:

A Patient Billing Documentation Auditor is responsible to review clinical documentation and billing records of hospital services rendered for conducting defense audits with payers and obtain accurate documentation necessary to ensure compliance and accuracy for denials and appeals.


  1. Associates degree in Nursing required.
  2. BSN, MSN, or equivalent clinical degree preferred.
  3. RN License preferred.
  4. Certified Medical Auditor Specialist preferred.
  5. 3-5 years of experience in clinical decision making a plus.
  6. Excellent investigative and analytical skills and demonstrate advance proficiency in determining medical necessity in compliance with CMS standards of care.
  7. Able to perform detailed analytical reviews and calculations.
  8. Possesses strong understanding of coding systems such as ICD10, HCPCS, CPT, DRG and APC’s.
  9. Excellent oral and written communication skills and the ability to handle highly sensitive issues with the utmost professionalism, tact and diplomacy.
  10. Ability to work independently, self-motivated and an ability to adapt to the changing healthcare environment.

Essential Functions and Responsibilities:

  1. Responsible for daily operations of Medical Financial Review office.
  2. Identifies, documents and communicates trends in recurring medical necessity denials and recommends process improvements to eliminate future denials.
  3. Performs research to remain up to date with best practice standards, coding standards and federal regulations.
  4. Responsible to coordinate meeting/or conference call with Insurance Auditors to resolve audit findings and sign approval form.
  5. Conducts compliance audits and investigations. Consults with legal services as well as reporting of non-compliance to Revenue Cycle Committee.
  6. Identifies & researches areas of deficiencies and/or discrepancies when comparing hospital claim forms with patient’s medical record along with educating departments and provide recommended solutions.
  7. Ability to understand and apply complex charging methodology from revenue producing departments.
  8. Coordinates the medical necessity denials process in collaboration with the Attending Physician, Health Information Management and Patient Financial Services.
  9. Ability to recognize key clinical indicators in patient records to identify opportunities to query clinicians for documentation of diagnosis or procedures needed to obtain appeal denials for appropriate reimbursement for services rendered.
  10. Other duties and projects as assigned.
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