RN-Clinical Auditor Manager, Care Transformation - Case Management
Company: SSM Health
Location: Saint Louis
Posted on: October 16, 2024
Job Description:
It's more than a career, it's a callingMO-SSM Health Mission
HillWorker Type:RegularJob Highlights:
RN-Clinical Auditor Manager, Care
Transformation - Case Management -and Social Work7 year's relevant
experience -in clinical auditing is required.Ideal candidate has
experience and knowledge of inpatient/acute Case Management. Job
Summary:Ensures the daily management of auditing, monitoring of
processes, reporting, and outcomes to ensure Care Transformation is
compliant with regulatory requirements and standards are
maintained. Performs clinical audits within Care Transformation
operations by supporting the Clinical Documentation Improvement,
Utilization Management, Status Review, and Case Management
departments. Performs operational audits and compliance audits
adhering to regulatory requirements. Standardizes policies,
procedures and reporting for all auditing procedures.Job
Responsibilities and Requirements:PRIMARY RESPONSIBILITIES
- Creates and maintains auditing tools, procedures, and reporting
for all areas of Care Transformation operations: Clinical
Documentation Improvement; Utilization Management and Status
Review; Case Management Standard Work. -
- Performs operational and compliance audits adhering to
regulatory requirements. -
- Creates and standardizes policies, procedures and reporting for
all auditing procedures. -
- Reviews patient medical record documentation related to
Clinical Documentation Improvement, Utilization Management and
compares against medical bills, claims and revenue reports.
- Participates in training of specific area of focus by tailoring
to specific needs identified within auditing findings. -
- Utilizes auditing data, along with data analysts/liaisons, to
improve risk adjustment measures and denial management processes
within department. -
- Resolves inquiries from internal and external sources to
reconcile accounts accurately and within compliance guidelines.
-
- Ensures compliance with government and billing guidelines by
reviewing and splitting or combining claims per clinical/billing
guidelines. Enhances net revenue by splitting charges that should
be presented on separate claims to capture entitled revenue. -
- Improves claim submissions by reviewing, researching,
resolving, and trending claim issues in a timely manner. -
- Performs other duties as assigned. -EDUCATION
- Graduate of accredited school of nursing or education
equivalency for licensingEXPERIENCE
- 7 year's relevant experience -in clinical auditingREQUIRED
PROFESSIONAL LICENSE AND/OR CERTIFICATIONS - -State of Work
Location: Illinois -
- Registered Professional Nurse (RN) - Illinois Department of
Financial and Professional - - -Regulation (IDFPR) - - - - -State
of Work Location: Missouri -
- - - -Registered Nurse (RN) Issued by Compact State -
- - - -Or -
- - - -Registered Nurse (RN) - Missouri Division of Professional
Registration - -State of Work Location: Oklahoma -
- - - -Registered Nurse (RN) Issued by Compact State -
- - - -Or -
- - - -Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) -
- - - -State of Work Location: Wisconsin -
- - - -Registered Nurse (RN) Issued by Compact State -
- - - -Or -
- - - -Registered Nurse (RN) - Wisconsin Department of Safety and
Professional ServicesWork Shift:Day Shift (United States of
America)Job Type:EmployeeDepartment:8764070033 System Care
CoordinationScheduled Weekly Hours:40SSM Health is an equal
opportunity employer. SSM Health does not discriminate on the basis
of race, color, religion, national origin, age, disability, sex,
sexual orientation, gender identity, pregnancy, veteran status, or
any other characteristic protected by applicable law. Click here to
learn more. Benefits SSM Health values our exceptional employees by
offering a comprehensive benefits package to fit their needs. -
- Paid Parental Leave: we offer eligible team members one week of
paid parental leave for newborns or newly adopted children
(pro-rated based on FTE). -
- Flexible Payment Options: -our voluntary benefit offered
through DailyPay offers eligible hourly team members instant access
to their earned, unpaid base pay -(fees may apply) -before
payday.
- Upfront Tuition Coverage: -we provide upfront tuition coverage
through FlexPath Funded for eligible team members. -
Keywords: SSM Health, Belleville , RN-Clinical Auditor Manager, Care Transformation - Case Management, Executive , Saint Louis, Illinois
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