Revenue Integrity Nurse Auditor PSJH - Orc Revenue Optimization Admin at Revenue Cycle Business Services
The Nurse Auditor is responsible for providing patient focused, standardized, compliant revenue cycle support that will assist Providence St Joseph Health to in meeting financial objectives.
Conduct audits (individual chart/bill audits, focus audits, compliance audits, payer defense audits and patient requests for audit).
Review and assess the accuracy of charges and CPT/HCPCS coding, the documentation of orders and clinical documentation to support charges, and the processes used by the ancillary departments for insuring charge capture and appropriate documentation.
Analyze audit results and report findings to promote and improve compliant processes.
Assist in the research and coordination of compliance related information for the compliance program.
Provide recommendations to align with best practices.
Appeal and manage the lack of payment (denials) from insurance plans (Payors).
Work collaboratively with the Payors, RCS, Case Management, Admitting and Medical Records to resolve existing denials and maximize processes to reduce future denials for accurate and timely reimbursement.
Educate ministries on regulatory procedures to maintain compliance and integrity of the revenue cycle and charge capture.
Serve as Subject Matter Expert on multiple processes and procedures to assist management with projects relating to the Compliance program.
• Independently conduct revenue audits including bill audits, focus audits, compliance audits, government audits and patient requests. Gather and review all necessary clinical documentation and compare to the final edited bill. Use clinical expertise and knowledge of Medicare or payer billing requirements, to evaluate the accuracy of billed charges and hospital’s compliance with Medicare and other billing rules.
• Develop, monitor, and report key measurements, trends and audit results to RI-CDM management.
• Collaborate with facilities to identify minimum specifications and/or processes each need in place to support compliant and accurate clinical documentation that supports medical necessity and other regulatory requirements.
• Collaborate with facilities to identify and develop needed resources to provide education and evaluation of clinical documentation.
• Interpret and communicate regulatory standards and their implications to clinicians and key internal constituents.
• Document and communicate recurring problems, including business impact and possible resolutions.
• Take initiative in investigating and resolving claim and charging issues.
• Independently address patient, department and administrative requests for a variety of issues related to revenue and charge integrity.
• Reduce reporting variations by working with business office departments to identify issues impeding accurate, timely and relevant reporting.
• Manage payer denials after the Hospital PFS or Case Manager identifies the denial by gathering/reviewing all necessary clinical and non-clinical documentation.
• Review recommendations as subject matter expert to ensure recommendations are sustainable.
• Work with RI-CDM Department and Internal Audit, providing audit related assistance as needed.
• Investigate medical record and charge entry discrepancies, analyze information, and make recommendations for corrections or process improvements.
• Serve as a primary revenue integrity resource and liaison for charge producing departments, RBO, HIM-Coding, Case Management and Admitting.
• Team Work:
• Works effectively with team members across functional and geographic regions (good at working with team members who are not in a direct reporting line relationship).
• Takes responsibility to support team members in meeting project milestones and objectives (even when team members or milestones pertain to different projects and audits).
• Listens with sensitivity and openness.
• Actively seeks constructive feedback and remains open and receptive to it.
• Provides the information needs of customers.
• Communicates effectively with technical staff and with customers.
• Customer Service:
• Takes personal responsibility for customer satisfaction and service excellence.
• Consistently goes out of the way to listen, understand and support the needs of others in a sensitive manner.
• Performs tasks efficiently and effectively.
• Sets objectives and works against self-defined standards of excellence to continually improve personal performance.
• Ensures that any documents produced are proofed for accuracy and prepared as "ready to release".
• Shows competent planning and project management skills.
• Anticipates and responds proactively in a dynamic environment.
• Maintains focus on Mission and core values.
• Problem Solving:
• Shows strong attention to detail and strong analytical skills.
• Demonstrates good communication skills and the ability to work effectively to build relationships with colleagues and customers through positive interaction.
• Flexibility and response to change/Dealing with ambiguity:
• Organizes projects and demands able to meet shifting priorities with minimal guidance.
• Takes responsibility for meeting all project deadlines.
Associate's Degree or Bachelor's Degree in Nursing.
5 years Clinical experience in an acute care setting.
Experience working with revenue cycle team members to accomplish specific objectives.
Experience in a high production, deadline-oriented professional work environment requiring multi-tasking, flexibility, and self-directed work.
Proven track record in identifying and resolving inefficiencies in charge capture and revenue cycle processes.
A track record in organizing and planning with demonstrated ability to effectively manage time and achieve results in a fast paced environment.
3 years working in case management or similar function in an acute care setting
3 years of experience actively utilizing EPIC and the reporting functions.
1 year experience in a multi-hospital and/or integrated healthcare system.
1 year familiarity with Revenue Cycle processes.
Case Management Healthcare Professional.
Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.
About the department you will serve.
One Revenue Cycle (ORC) is the name adopted to reflect the Providence employees who work throughout Providence Health & Services (PH&S) in revenue cycle systems and structures in support of our ministries and operations in all regions from Alaska to California. ORC’s objective is to ensure our core strategy, One Ministry Committed to Excellence, is delivered along with the enhanced overall patient care experience (know me, care for me, ease my way) by providing a robust foundation of services, operational and technical support, and the sharing of comprehensive, relevant, and highly specialized revenue cycle expertise.
We offer a full comprehensive range of benefits — see our website for details — http://www.providenceiscalling.jobs/rewards-benefits
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Administrative (Clinical)
Other Location(s): Montana, California, Washington, Oregon, Texas, Alaska
Req ID: 366766