RN, Provider Clinical Compliance Auditor- Remote - Baystate Health
Springfield, MA
About the Job
Baystate Health, a nationally recognized leader in healthcare quality and safety, and home to Baystate Medical Practices, the largest multispecialty group in the region is looking for an experience RN, Provider Clinical Compliance Auditor to join the Baystate Medical Practice Revenue Integrity Team
Full Time -Remote Opportunity - ( Current States eligible for remote: CT, FL, MA, RI, VT, )
Under the direct supervision of the Manager, the RN, Provider Clinical Compliance Auditor for Baystate Medical Practices, reviews and responds to external carrier audits to determine if the documentation in the medical record supports the charges that are on the account, identifies previously omitted or incorrect charges, write and submit appeals, assist departments in conducting root cause analysis and re-education when no grounds to appeal are found, and the auditor’s decision is accepted. Assists audit services and Corporate Compliance Staff as needed. Consistently applies corporate values and the constant pursuit of excellence in improving the health status of people to help fulfill the Baystate mission. RN, Provider Clinical Compliance Auditor Is responsible for knowing and acting in accordance with the principles of the Corporate Compliance, BMP Revenue Integrity unit, BMP policies and procedures for MA providers, and Code of Conduct. Working in collaboration with members of management establishes priorities and works to ensure effective utilization of resources to meet established operational goals and objectives, promotes an ethical corporate business culture to assure the compliance of BMP providers with all laws and regulations related to achieving the corporate mission, BMP mission, and strategic plans.
Job Requirements:
+ Under the supervision of the Manager, the Clinical Compliance Auditor applies experienced-based knowledge of medical diagnoses and service-specific standard practices and treatment protocols as well as third-party standards for allowable charges to conduct proactive and retrospective audits and to respond to external audits to verify that medical record documentation supports hospital and ancillary charges. Analyzes provider charges, medical records, and other source documentation; manages third-party provider audits and validates results; locates required documentation; identifies, records, and summarizes related information on charges to be submitted for payment or credit. Works with appropriate documentation to ensure charge-related findings are fully resolved.
+ Maintain and update audit status information in the audit tracking application, including documentation of the audit stage and resolution.
+ Reviews external audit findings and recommendations with department management, providing advice and counsel to same as needed. Ensures that the external audit tracking tool documentation remains current and creates monthly reports of external audit activities for management.
+ Identifies and documents potential compliance or utilization issues.
+ Maintains up-to-date knowledge of changes to various third-party standards for documenting charges and recommends modification of internal procedures.
+ Works independently while conducting and responding to audits or investigations. Utilizes Project Management skills to organize, conduct, or respond to 3rd party audits.
+ Assists in the coordination and resolution of all 3rd party clinical billing audits and maintains databases related to payor and contract audits and results.
+ Researches information when necessary, i.e., internet searches, computer literate in EMR and clinical systems.
+ Conducts investigations arising from patient complaints and investigates high-risk areas identified by federal and state regulatory officials or third-party payers.
+ Sets up and maintains required records, documents, reports, correspondence specifications, and other data related to 3rd party audits and analyses. Ensures data is accurate and complete.Creates corrective action plans.Works with various departments, including the key Revenue Cycle teams and Managed Care Contracting, to enhance charge processing and documentation.
+ Develop training materials and conduct sessions with BMP providers and personnel to address procedures such as charge protocols and medical record documentation.
+ Oversight of work of documentation auditors
Required Experience:
+ Registered Nurse with a minimum of 3-5 years
+ Knowledge of Medicare Payment Systems, accurate reporting and sequencing of principal and secondary diagnoses and procedures,
+ Knowledge of Local Medical Review Policies/Local Coverage Determinations, National Coverage Determinations, CPT-4, ICD-10, and HCPCS.
+ Ideal candidate will have knowledge & understanding of Massachusetts practitioner regulations and guidelines.
+ Strong knowledge of Microsoft Office, including Excel Power Point
+ Utilization Management experience is a plus.
D emonstrated Skills and Competencies
+ Excellent interpersonal, verbal, and written communication skills are required, including the ability to perform interviews and presentations, write concise reports and educate.
+ Ideal candidate will have strong analytical, organizational, and time management skills with exceptional attention to detail.
+ Ability to work with a high degree of independence and be motivated and adept at developing and learning new skill sets.
Advantages of Working with Baystate Health
+ Established career ladders with guaranteed compensation increases.
+ Excellent Benefits, Compensation and generous PTO
+ Nursing forgivable loan program
+ First time home buyers’ program
+ High-quality, low-cost medical, dental and vision Insurance
+ Competitive 403b retirement match
+ Wellbeing programs that include but are not limited to mental, physical and financial health.
We strive to be the place where we can help you build the career you deserve – apply today – YOU belong at Baystate!
You Belong At Baystate
At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.
DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.
Education:
Bachelor of Science, Diploma in Nursing (Required)
Certifications:
Registered Nurse - State of MassachusettsState of Massachusetts
Equal Employment Opportunity Employer
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
Full Time -Remote Opportunity - ( Current States eligible for remote: CT, FL, MA, RI, VT, )
Under the direct supervision of the Manager, the RN, Provider Clinical Compliance Auditor for Baystate Medical Practices, reviews and responds to external carrier audits to determine if the documentation in the medical record supports the charges that are on the account, identifies previously omitted or incorrect charges, write and submit appeals, assist departments in conducting root cause analysis and re-education when no grounds to appeal are found, and the auditor’s decision is accepted. Assists audit services and Corporate Compliance Staff as needed. Consistently applies corporate values and the constant pursuit of excellence in improving the health status of people to help fulfill the Baystate mission. RN, Provider Clinical Compliance Auditor Is responsible for knowing and acting in accordance with the principles of the Corporate Compliance, BMP Revenue Integrity unit, BMP policies and procedures for MA providers, and Code of Conduct. Working in collaboration with members of management establishes priorities and works to ensure effective utilization of resources to meet established operational goals and objectives, promotes an ethical corporate business culture to assure the compliance of BMP providers with all laws and regulations related to achieving the corporate mission, BMP mission, and strategic plans.
Job Requirements:
+ Under the supervision of the Manager, the Clinical Compliance Auditor applies experienced-based knowledge of medical diagnoses and service-specific standard practices and treatment protocols as well as third-party standards for allowable charges to conduct proactive and retrospective audits and to respond to external audits to verify that medical record documentation supports hospital and ancillary charges. Analyzes provider charges, medical records, and other source documentation; manages third-party provider audits and validates results; locates required documentation; identifies, records, and summarizes related information on charges to be submitted for payment or credit. Works with appropriate documentation to ensure charge-related findings are fully resolved.
+ Maintain and update audit status information in the audit tracking application, including documentation of the audit stage and resolution.
+ Reviews external audit findings and recommendations with department management, providing advice and counsel to same as needed. Ensures that the external audit tracking tool documentation remains current and creates monthly reports of external audit activities for management.
+ Identifies and documents potential compliance or utilization issues.
+ Maintains up-to-date knowledge of changes to various third-party standards for documenting charges and recommends modification of internal procedures.
+ Works independently while conducting and responding to audits or investigations. Utilizes Project Management skills to organize, conduct, or respond to 3rd party audits.
+ Assists in the coordination and resolution of all 3rd party clinical billing audits and maintains databases related to payor and contract audits and results.
+ Researches information when necessary, i.e., internet searches, computer literate in EMR and clinical systems.
+ Conducts investigations arising from patient complaints and investigates high-risk areas identified by federal and state regulatory officials or third-party payers.
+ Sets up and maintains required records, documents, reports, correspondence specifications, and other data related to 3rd party audits and analyses. Ensures data is accurate and complete.Creates corrective action plans.Works with various departments, including the key Revenue Cycle teams and Managed Care Contracting, to enhance charge processing and documentation.
+ Develop training materials and conduct sessions with BMP providers and personnel to address procedures such as charge protocols and medical record documentation.
+ Oversight of work of documentation auditors
Required Experience:
+ Registered Nurse with a minimum of 3-5 years
+ Knowledge of Medicare Payment Systems, accurate reporting and sequencing of principal and secondary diagnoses and procedures,
+ Knowledge of Local Medical Review Policies/Local Coverage Determinations, National Coverage Determinations, CPT-4, ICD-10, and HCPCS.
+ Ideal candidate will have knowledge & understanding of Massachusetts practitioner regulations and guidelines.
+ Strong knowledge of Microsoft Office, including Excel Power Point
+ Utilization Management experience is a plus.
D emonstrated Skills and Competencies
+ Excellent interpersonal, verbal, and written communication skills are required, including the ability to perform interviews and presentations, write concise reports and educate.
+ Ideal candidate will have strong analytical, organizational, and time management skills with exceptional attention to detail.
+ Ability to work with a high degree of independence and be motivated and adept at developing and learning new skill sets.
Advantages of Working with Baystate Health
+ Established career ladders with guaranteed compensation increases.
+ Excellent Benefits, Compensation and generous PTO
+ Nursing forgivable loan program
+ First time home buyers’ program
+ High-quality, low-cost medical, dental and vision Insurance
+ Competitive 403b retirement match
+ Wellbeing programs that include but are not limited to mental, physical and financial health.
We strive to be the place where we can help you build the career you deserve – apply today – YOU belong at Baystate!
You Belong At Baystate
At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.
DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.
Education:
Bachelor of Science, Diploma in Nursing (Required)
Certifications:
Registered Nurse - State of MassachusettsState of Massachusetts
Equal Employment Opportunity Employer
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
Source : Baystate Health
