Medical Review Clinical Appeals Auditor (RN)

The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditees, disputing all or part of the findings from medical review audit work completed by the medical review clinical audit team members, and communicating and supporting the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools.

This role also requires consistently achieving or exceeding productivity goals and quality standards, serving as a subject matter expert, providing supplemental escalation support, and may perform special project activities as needed.

Key Responsibilities

• Performs clinical reviews on medical records to maintain subject matter expertise.
• Conducts Appeals reviews on medical review audit work completed by the medical review clinical and documentation audit team members, as new evidence is presented by auditees.
• Objectively and accurately documents Appeals results in accordance with department quality policies and procedures, scoring and reporting all Appeals results and routes the result appropriately within the audit platform based upon how the Appeal review resulted in a full or partial upholding of the audit finding or with a full or partial overturn.
• Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings.
• Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings.
• Contributes to the continuous improvement feedback process and suggests any edits to documentation, enhancements to review guidelines, and reporting as may be necessary.
• May support findings during the appeals process, if needed.
• May perform primary audit activity as assigned by management.
• Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction.
• May prepare reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept-based/trended, or other characteristics that will provide valuable business insights.
• Consults with internal resources as necessary.
• Becomes subject matter expert for assigned business segment(s).
• Maintains current knowledge and changes that affect the industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.
• Participates in and contributes to applicable department meetings.
• Successfully completes, retains, applies, and adheres to content in required training, including information security, anti-harassment, and other compliance and policy/procedures training.
• Proactively contributes to continuous improvement of activities and sets a positive example.
• Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.
• May support training material/tools and best practices development.
• May identify/make recommendations to management for supplemental team/concept type training.
• May support training activities for new audit staff or provide supplemental training for existing staff as needed.
• Contributes to a positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.
• Receives feedback and adjusts work priority as necessary.
• Serves as a positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations, and law.
• Performs job duties with a high level of professionalism and maintains confidentiality.
• Performs other incidental and related duties as required and assigned to meet business needs.

Knowledge, Skills, and Abilities Needed

• Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others.
• Must be able to manage multiple assignments effectively, create documentation outlining findings, Appeals review results, and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.
• Experience with CPT/HCPCS/ICD-9/ICD-10/MS-DRG coding may be necessary.
• Strong knowledge of medical documentation requirements and an understanding of CMS, Medicaid, and/or Commercial insurance programs, particularly the coverage and payment rules and regulations, may be necessary.
• Experience with utilization management systems or clinical decision-making tools such as Milliman Care Guidelines (MCG) or InterQual.
• Working knowledge of an encoder may be necessary.
• Reimbursement policy and/or claims software analyst experience may be necessary.
• Familiarity with interpreting electronic medical records (EHR).
• Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.
• Demonstrated ability to consistently apply sound judgment and effective decision-making.
• Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals.
• Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions.
• Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal and external.
• Demonstrated ability to collaborate effectively in a variety of settings and topics.
• Excellent editing and proofreading skills.
• Ability to independently organize, prioritize, and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.
• Excellent time management and delivers results balancing multiple priorities.
• Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to complement data.
• Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.
• Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.
• Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
• Ability to create documentation outlining findings and/or documenting suggestions.
• Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate-to-Advanced Excel Skills), application reporting tools, and case management system/tools to review and document findings.
• Advanced technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.
• Ability to be flexible and thrive in a high-pace environment with changing priorities.
• Adaptable to applying skills to diverse operational activities to support business needs.
• Self-starter with the ability to work independently in a remote setting with minimum supervision and direction in the form of objectives.
• Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high-performing teams.
• Capability of working in a fast-paced environment, flexibility with assignments, and the ability to adapt in a changing environment.

Required and Preferred Qualifications

• Active unrestricted RN license in good standing and diversified nursing experience providing direct care in an inpatient or outpatient setting, is required.
• At least 5+ years relevant SNF/MDS experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position. Less than 5 years may be considered for internal candidates based upon demonstrated skills and results.
• Not currently sanctioned or excluded from the Medicare program by OIG.
• Must have strong technical aptitude and intermediate to advanced skills using Excel.
• One or more years of experience in healthcare claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies, and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider may be required.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• Prior experience in a role with responsibility for conducting primary audit, utilization management, or prior-authorization work, or review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.).
• Prior experience in payer edit development and/or reimbursement policy is a plus.
• Prior experience working in a remote setting is strongly preferred. Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance.