Clinical Appeal Revenue Integrity Nurse Auditor

Regular Full-Time

Location:

225 Willow Brook Road, Freehold, NJ

Job Category:

CentraState Healthcare System

Primary Shift:

Day

Work Schedule:

9A-5P

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Overview

The Revenue Integrity Nurse Auditor is responsible for auditing documentation meet medical necessity requirements, performing insurance defense audits and constructing formal appeal letters. The Revenue Integrity Nurse Auditor will work with various ancillary departments, outpatient departments, Health Information Management (HIM), Patient Financial Services (PFS), Compliance and physicians to ensure charge capture and documentation consistently meets regulatory guidance and medical necessity requirements.  Communicates all audit findings with the necessary parties and works closely with external auditors to resolve discrepancies.  This person will collaborate with the Revenue Cycle team to set goals and identify any opportunities for improvement or policy changes. 

Responsibilities

  • Responsible for auditing documentation related to regulatory compliance, charge capture, and medical necessity for the outpatient lines of business.
  • Conducts medical necessity reviews of surgical cases prior to procedure to ensure medical necessity is met according to payer guidance.
  • Conducts ongoing/retrospective charge audits for the purpose of identifying charging and billing weaknesses, revenue leakage, and possible compliance issues and reports discrepancies to the appropriate departments and makes specific recommendations in order to minimize their recurrence and reduce regulatory non-compliance.
  • Assists with medical necessity denials by addressing regulatory compliance and payer guidelines, as well as constructs appeal letters.
  • Operates as a clinical resource and provides departmental education on regulatory compliance related to charge functioning. 
  • Operates as a clinical resource for coding/denial management.
  • Prepares trend and other reports related to revenue at risk and denial activity
Qualifications

Education: Bachelors in Nursing preferred.

 

Experience: Minimum three years experience in a clinical setting.

 

Licenses and Certifications: Current NJ RN license required.

 

Required Knowledge and Skills:

Strong broad-based clinical knowledge and understanding of pathology/physiology of disease process.  

Excellent written and verbal communication skills.

Excellent critical thinking skills.

Excellent interpersonal skills to build effective partnering relationships with physicians, and hospital staff. Ability to work independently in a time oriented environment.

Knowledge of care delivery documentation systems and related medical record documentation.

Proficient in Microsoft Office (Word, Excel, Outlook, etc).

 

About Us

CentraState Healthcare System, a partner of Atlantic Health System, is a fully accredited, not-for-profit, community-based health system that provides comprehensive health services in the central New Jersey region. In addition to offering a full range of leading-edge diagnostic and treatment options, CentraState serves as a valuable health partner focused on the latest ways to prevent disease, promote healthy behaviors, and help people of all ages live life well. Based in Freehold, CentraState is comprised of a 284-bed acute-care hospital, a vibrant health and wellness campus, three award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions offering primary care and specialty physician practices, along with access to outpatient services, such as lab and physical therapy. The system also offers a family medicine residency and geriatric fellowship training program in affiliation with Rutgers Robert Wood Johnson Medical School. Among its many honors and accreditations, CentraState is one of less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence four times and was designated a Great Place to Work-Certified™ Company by Great Place to Work® for the second consecutive year.

 

When you bring your talent to CentraState, you are joining a trailblazing healthcare facility, committed to providing high-quality, patient-focused care. Join us in making incredible strides in health care, and making a difference in our community. We believe in enriching the lives of our employees through work/life balance initiatives, tuition assistance, career advancement opportunities and much more.

 

Find out why our employees love their jobs and being part of the CentraState family!

 

What We Offer:

  • Highly competitive compensation
  • Excellent benefits package and rewards program
  • 403(b) retirement plan with company match
  • 401(a) retirement plan with employer contribution
  • Life Insurance 
  • Tuition Reimbursement Program
  • Profit Sharing Program
  • Growth Opportunity and Workforce Development Initiatives
  • Continuing Education / Onsite Training
  • A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
  • Concierge Services with Work & Family Benefits
  • Magnet recognized healthcare facility
Commitment to Diversity and Inclusion

At CentraState Healthcare System, we welcome and promote the diversity of our employee family!  Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.

 

CentraState Healthcare System, is an equal employment opportunity employer and federal contractor or subcontractor and, therefore, abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, gender identity or expression, sexual or affectional orientation, national origin or nationality, citizenship status, disability, age, genetics, protected veteran status, ancestry, marital status.