Clinical Nurse Auditor - Rev Cycle
The University of Kansas Health System · United States
- Hybrid
- Full-time
- $85,000 / year
- United States
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Job highlights
- Audit clinical documentation for revenue cycle optimization.
- Manage denials and secure upfront patient authorizations.
- Collaborate across departments to resolve account issues.
- Ensure compliance with healthcare regulations and standards.
- Utilize RN expertise in review and process improvement.
About the role
Clinical Nurse Auditor - Rev Cycle
Position Summary / Career Interest
This remote, full-time position involves working with pre-certification/authorization and denials teams to secure upfront authorization for services. Key responsibilities include leveraging clinical expertise for chart reviews, understanding peer-to-peer requirements, and appeal processes. The role also supports denial management and resolution, collaborating with HIM, PFS, Case Management, and clinical departments to resolve authorization and account issues. For the Clinical Trials business line, duties include reviewing protocols to ensure billed services as standard of care are evidence-based and align with industry guidelines, and identifying all services rendered as part of a trial.
Responsibilities And Essential Job Functions
- Responsible for decreasing denied and inappropriately paid claims due to clinical or administrative reasons.
- Performs utilization review for correct patient setting (IP, OP, Observation), Medical Necessity, Charge Audit reviews, and addresses missing or undocumented charges.
- Completes documentation to support services per peer standards, focusing on high dollar & high-risk areas like transplants, Cancer Center, and Cardiology.
- Uses clinical expertise for ongoing reviews of medical record documentation and clinical pertinence according to peer standards and Medicare Regulations.
- Assists in tabulating results and reporting to management.
- Supports process improvement activities to ensure medical record compliance with regulatory and accreditation bodies.
- Collaborates with HIM coding staff and Patient Financial Services to resolve account problems related to clinical information.
- Monitors process effectiveness to identify trends and improvement opportunities.
- Assists with the development, implementation, and testing of process improvement plans.
- Supports quality improvement initiatives across the continuum of care, including Authorization, Eligibility, Medical Necessity, Utilization Review, Documentation, and Patient Status.
- Evaluates and resolves revenue cycle issues such as medical documentation, utilization review, and medical necessity.
- Assists with documentation support and issue resolution in areas of charge capture, charge master, coding, claim submission, and information systems.
- Works with various departments and physician offices to resolve revenue cycle process conflicts.
- Provides training to improve revenue cycle processes.
- Recommends policy and procedure improvements to increase efficiencies.
- Provides education and feedback to medical and ancillary staff to improve medical record documentation, patient status orders, and clinical pertinence.
Required Education And Experience
- Bachelor's Degree in Nursing.
- 2 or more years of experience in utilization review, clinical review, or authorizations.
Preferred Education And Experience
- EPIC experience.
Required Licensure And Certification
- Licensed Registered Nurse (LRN) - Multi-State.
- Current State RN license.
Key skills/competency
- Clinical Nurse Auditor
- Revenue Cycle Management
- Utilization Review
- Medical Necessity
- Denial Management
- Authorization
- Clinical Documentation
- Registered Nurse
- Chart Review
- Healthcare Regulations
Skills & topics
- Clinical Nurse Auditor
- Revenue Cycle
- Utilization Review
- Denial Management
- Medical Necessity
- Authorization
- Registered Nurse
- RN
- Healthcare
- Auditing
- EPIC
- Remote
How to get hired
- Tailor your resume: Highlight your RN experience, utilization review, and revenue cycle skills, specifically mentioning authorization and denial management.
- Showcase your expertise: Emphasize your clinical knowledge in areas like medical necessity and chart review, aligning with the job description's requirements.
- Demonstrate understanding: Research The University of Kansas Health System's commitment to quality patient care and revenue cycle efficiency.
- Prepare for interviews: Be ready to discuss specific examples of how you've reduced denied claims or improved authorization processes using your clinical judgment.
- Highlight relevant software: If you have EPIC experience, be sure to mention it prominently on your application and resume.
Technical preparation
Master EHR systems like EPIC thoroughly.,Study Medicare and payer regulations.,Practice chart auditing techniques.,Understand revenue cycle workflows.
Behavioral questions
Describe handling conflicting information.,How do you manage denial appeals?,Share an improvement you suggested.,How do you ensure documentation accuracy?
Frequently asked questions
- What is the role of a Clinical Nurse Auditor at The University of Kansas Health System?
- A Clinical Nurse Auditor at The University of Kansas Health System reviews medical records and clinical documentation to ensure accurate billing, reduce claim denials, and manage the revenue cycle. This involves utilization review, verifying medical necessity, and securing authorizations for services.
- What qualifications are essential for the Clinical Nurse Auditor - Rev Cycle position?
- Essential qualifications include a Bachelor's Degree in Nursing, a current RN license, and at least two years of experience in utilization review, clinical review, or authorizations. Strong clinical expertise and knowledge of healthcare regulations are also critical.
- Is the Clinical Nurse Auditor position remote?
- Yes, the Clinical Nurse Auditor - Rev Cycle position at The University of Kansas Health System is a remote role, offering flexibility for qualified candidates.
- What experience with healthcare systems is preferred for this role?
- While not strictly required, experience with the EPIC electronic health record system is preferred for the Clinical Nurse Auditor position, as it can streamline workflow and data access.
- How does this role contribute to The University of Kansas Health System's revenue cycle?
- This role directly contributes by decreasing denied claims, ensuring appropriate payment for services rendered, and optimizing the authorization process, thereby improving the overall financial health of the health system.
- What kind of collaboration is expected in this Clinical Nurse Auditor role?
- The Clinical Nurse Auditor will collaborate with various teams including HIM, PFS, Case Management, clinical departments, and physician offices to resolve authorization issues, account problems, and improve revenue cycle processes.
- Are there specific high-risk areas this Clinical Nurse Auditor will review?
- Yes, the role involves reviewing high dollar and high-risk areas such as transplants, the Cancer Center, and Cardiology, requiring specialized clinical knowledge.