Revenue Cycle Medical Billing Resource Utilization Clinical Auditor - Located in West Plains, MO

Job Summary

Review and audit medical necessity justification for air and ground ambulance transports, evaluate, and submit all medical necessity appeals for commercial payors. Utilize clinical experience, established clinical standards and protocols to validate air medical necessity and appeal payment denials.

Essential Functions/Duties

• Conduct audits of the medical necessity appeals for all payor sources in the role of advocate for the patient and GMR.
• Ensure appeal timelines are met by moving the assigned book of business through the appeals process and updates appeals database.
• Work with fixed deadlines and demonstrate willingness to meet and exceed performance metrics.
• Work with the Appeal team to determine the best approach to each clinical denial in order to maximize claim reimbursement and minimize the financial risk to patients and GMR.
• Maintain strict confidentiality of all protected health information and cooperate fully with all information security guidelines related to the scope of work.

Qualifications

• Required: Licensed RN with minimum of five years in Emergency department (ED), Intensive Care Unit (ICU), flight or ambulance experience or job experience equivalent.
• Preferred: Some supervisory/leadership experience (i.e.: team leader, FTO, charge nurse, preceptor, educator, etc.).
• Education/Licensure: Current RN licensure, is required; Bachelor’s degree in nursing or equivalent, is preferred; CFRN, CEN or CCRN, is preferred.

Skills

• Excellent written communication skills.
• Define and identify problems, collect data, establish facts, and draw valid conclusions.
• Respond to inquiries or complaints from customers in a positive and productive manner.
• Calculate numbers, correct entries, and post to records.
• Gather data from hospital and EMS charts, phone calls, emails, colleagues, and internet research, then compile information and prepare reports and letters.
• Use independent judgment and impart confidential information.
• Research local EMS protocols, hospital referrals, and standards of care.
• Review clinical charts and develop constructive feedback.

Benefits

Check out our careers site benefits page to learn more about our benefit options.

Pay

$73,000 (this position is bonus eligible)

Schedule

Full-Time Exempt