As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.

The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence based medicine, community and national medical management and coding standards and protocols.
• Performs reviews of accounts denied for DRG validation and DRG downgrades.
• Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
• Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRGâ��s, Outlier Payments, and Stop Loss calculations.
• Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
• Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Effectively organizes work priorities
• Demonstrates compliance with departmental safety and security policies and practices
• Demonstrates critical thinking, analytical skills, and ability to resolve problems
• Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
• Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
• Possesses excellent written and verbal communication skills
• Detail oriented and ability to work independently and in a team setting
• Moderate skills in MS Excel and PowerPoint, MS Office
• Ability to research difficult coding and documentation issues and follow through to resolution
• Ability to work in a virtual setting under minimal supervision
• Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes

EDUCATION / EXPERIENCE

Includes minimum education, technical training, and/or experience required to perform the job.

Education

Minimum Required:

• Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment
• RN License in the State of Practice
• Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.

Preferred/Desired:

• Completion of BSN Degree Program
• CCDS certification or inpatient coding certification

Experience

Minimum Required:

• Three to Five years Clinical RN Experience
• Three to Five years of Clinical Documentation Integrity experience
• Must have expertise with Interqual and/or MCG Disease Management Ideologies
• Strong communication (verbal/written) and interpersonal skills
• Knowledge of CMS regulations
• Knowledge of inpatient coding guidelines
• 1-2 years of current experience with reimbursement methodologies

Preferred/Desired:

• Experience preparing appeals for clinical denials related to DRG assignment.
• Strong understanding of rules and guidelines, including AHAâ��s Coding Clinics, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS

CERTIFICATES, LICENSES, REGISTRATIONS

• Required:
  • RN,
  • CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA
• Preferred: BSN

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to lift 15-30lbs
• Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
• Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

OTHER

• Interaction with facility HIM and / or physician advisors
• Must meet the requirements of the Conifer Telecommuting Policy and Procedure

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.