RN Clinical Auditor

Responsibilities

• Plan and perform audits and investigations focused on detecting and preventing fraud waste and abuse utilizing knowledge of CPT, ICD, HCPCS coding guidelines and regulations, benefit coverage, clinical medical and payment policies.
• Utilize various data mining tools to proactively identify outliers and potential case leads.
• Identify aberrant billing patterns resulting in overpayments or potential fraudulent activity.
• Obtain and review medical record documentation to prepare comprehensive clinical review/investigative summaries per SIU Standard procedures.
• Notify provider(s) of findings and provide feedback and education as necessary.
• Respond to appeals, prepare settlement agreements.
• Prepare accurate reporting to recoupment staff to initiate recovery of overpayments.
• Refer to Legal department as necessary for assistance with recoveries from non-responsive providers.
• Manage caseloads independently with attention to established timelines for casework ensuring timely follow up, audit completion and submission of recoupments and/or allegation of fraud to regulatory oversight agencies.
• Maintain documentation of case work per SIU standard policies and procedures to support mandated reporting.
• Core Contract reporting for EOHHS.
• Work collaboratively with and providing case updates on progress of investigations to management, SIU and Compliance team members, internal business leads related to case and external agencies as necessary.
• Communicate investigative findings and provide testimony in legal proceedings as required.
• Assist with RFI’s from external Regulatory and Law Enforcement agencies.
• Assist with education on fraud and abuse awareness, detection and reporting to business areas as required.
• Take responsibility for professional development, support a learning environment, and meet professional competency requirements.
• Perform other duties as assigned.

Qualifications

• Registered Nurse with an active, current, unrestricted license in RI in good standing
• Minimum of three (3) years experience in healthcare coding directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing, or health care quality improvement
• A high-level knowledge of medical terminology
• Proficient with various technology software tools, including Microsoft Office
• Excellent written and verbal communication skills, and strong attention to detail
• Ability to maintain confidentiality
• Ability to take direction and support a multitude of individuals
• Ability to work independently and prioritize activities