Shriners Hospitals for Children.
The Revenue\rIntegrity Therapy Auditor is responsible for auditing claims and charges to\rensure compliance with all State and Federal guidelines and regulations,\rappeals of clinical issues on claims, assisting with the review, analysis and\rresolution of denied, under-paid, and audited claims, coordinating efforts\rrelated to payer audits, and providing feedback to hospital charging\rdepartments on documentation, charges and charge master coding. The Revenue Integrity Therapy Auditor is responsible\rfor maintaining a detailed knowledge of Medicare RAC and corresponding Medicaid\rAudit procedures as well as Scope of Practice. \rThe person in this position is responsible for review and compliant\rfiling of responses to all audit requests to include Governmental Audits. The ideal candidate will be responsible for\ranalysis and interpretation of Third Party Payors and Governmental Payors\rclinical/medical necessity denials, as well as filing compliant appeals in\raccordance with Third party and governmental contracts.\r \rPOSITION\rRESPONSIBILITIES: \r\r \r Performs an audit of assigned cases comparing the bill to the\r medical record.\r \r \r Performs a detailed comparison of charges to documentation to\r ensure services documented have been captured through the charge process\r \r \r Performs a detailed comparison of charges to documentation to\r ensure services not documented are not charged.\r \r \r Reviews documentation to ensure that services typically performed\r with specific procedures are being documented so that charge capture may occur \r \r \r Review findings with the hospital representatives and obtains an\r agreement on the discrepancies.\r \r \r Demonstrates tact and understanding in handling problems, has a\r good rapport with hospital and corporate staffs.\r \r \r Initiates scheduling of the audit within 48 hours of receipt of\r the claim.\r \r \r Reports to the Revenue Integrity Director the audit status and\r initial findings within 24 hours of schedule date. \r \r \r Follows up on re-audits in a timely fashion to ensure that cases\r are completed.\r \r \r Reviews audit worksheets and charge totals by category with the\r bill to ensure a match. \r \r \r Re-checks mathematical computations before finalizing letter and\r report.\r \r \r Updates status of all cases assigned on minimum weekly basis\r \r \r Informs supervisor of any changes, problems, or concerns that\r arise at a facility.\r \r \r In the event of a dispute with the requesting party’s audit\r findings, files an appeal with the third party or governmental payor\r \r \r Analyzes and interprets all medical necessity/clinical denials\r from third party payors or governmental payors.\r \r \r Files appeals based on medical documentation and interpretation of\r medical necessity national professional organizational guidelines or InterQual or\r other criteria.\r \r
The\rqualified candidate will have experience in the following areas: \r\r Minimum\r of three years clinical experience required\r Current\r physical therapy license in the state of employment required\r Pediatric\r experience in acute care, inpatient rehab facility and/or outpatient\r settings preferred\r Demonstrable\r ability to communicate in writing and verbally in an effective manner,\r including spelling accuracy and legible writing skills, required\r Proficiency\r in mathematical skills required\r\r\rMinimum\rEducation Required/Preferred: \r\r \r High School Degree required\r \r\r\r Bachelor’s degree desired.\r MPT or DPT highly desired\r\r\r \r PT License required\r \r\r\rKnowledge,\rSkills, and Competencies:\r\r Knowledge of hospital clinical\r practice standards for health care providers\r Knowledge of physical therapy,\r occupational therapy and speech/language pathology service departments,\r quality control and safety standards\r Functional knowledge in criteria\r sets used to determine eligibility for rehabilitation services along the\r pediatric continuum of care\r General familiarity with electronic\r medical record coding systems\r Functional knowledge of DRG and CPT\r coding systems\r Working experience with Utilization\r Review activities and general knowledge of TJC, CMS, and/ state Medicaid\r as well as other regulatory bodies\r Knowledge of third party payer\r review, reimbursement systems and utilization monitoring requirements for rehabilitation\r services along the pediatric continuum of care\r Experience with reviewing hospital\r claims, denials and EOB's, appealing claims and working on claims in an\r audit is preferred\r Must be detail-oriented\r Must have ability to organize and\r prioritize\r Working knowledge of Microsoft\r computer applications; excel, word, PowerPoint, etc\r Working knowledge of 3M system \r Excellent written, verbal and\r presentation skills required; excellent business judgment, decision\r making, and business savvy are also essential\r Experience working collaboratively\r with IT, HIMS, Finance, Compliance, Managed Care, Business and Clinical\r Operations are important\r Strong understanding and\r appreciation for the automation of the revenue cycle functions and the\r engagement of the customer in that automated process\r Knowledge of\r applied statistics, process analysis, and outcomes analysis\r
Shriners Hospitals for Children.
Website : http://www.shrinershospitalsforchildren.org
Shriners Hospitals for Children offers career opportunities to clinical and non-clinical professionals; as well as educational and research opportunities. The work environment is mission driven, high qualiity and provides great satisfaction to all professionals through the unique health care setting. We are an equal employment opportunity employer committed to providing challenging and rewarding careers in an environment based on our corporate values – excellence, innovation, commitment, integrity, teamwork and stewardship. Careers are available in 22 hospitals and Shriners International Headquarters. The generous benefits package includes: Medical Dental Vision Paid leave Retirement Savings (403b)