Roles and Responsibilities
The Nurse Auditor is a key member of the Penstock team responsible for the interpretation and validation of medical record documentation to ensure billing for services is complete, accurate and follows all necessary coding and billing rules, policies, and guidelines.
Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify medical necessity issues, DRG discrepancies, and inappropriate coding or billing practices (e.g. upcoding, unbundling, investigational services, etc.).
Applies critical review judgment to make clinical determinations based on documentation reviewed and codes billed.
Identifies and refers scenarios that require input from the coding team.
Develops thorough, accurate and well-documented rationale in support of determination, citing appropriate guidelines (including MCG and IQ), policies, regulations, etc.
Prepares written responses and/or participates in conference calls regarding provider disputes of audit findings.
Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics.
Identifies and communicates new or expanded audit concepts and financial recovery opportunities.
Continuously considers the systems and processes involved with healthcare auditing (both internal and external) and communicates ideas for improvement.
Communicates effectively with other health care and/or coding professionals, both internal and external, regarding case- or concept-specific details or questions and refers issues to management as appropriate.
Participates in project data analysis, reporting, and feedback.
Shares ideas on clinical or coding topics through identification of needs or concerns within the payment integrity community.
Meets or exceeds Penstock’s performance and quality standards.
Qualifications and Education Requirements
We are looking for Registered Nurses who share our passion for getting to the truth, and who share our commitment to improving the way healthcare is paid for.
Minimum of an Associate degree
Active Registered Nurse (RN) license
3 or more years of clinical experience in a hospital setting
Previous recent experience in hospital medical record reviews/auditing
Comprehensive understanding of inpatient and outpatient hospital guidelines including coding, billing and CMS regulations
Demonstrated working knowledge Microsoft Word, Excel and PowerPoint
Comfortable working in an office environment
Must be able to work the Eastern Standard Time Zone
Able to apply analytical and critical thinking to record reviews
Ability to work independently and manage workload
Excellent writing, editing, interpersonal, planning, teamwork, and communications skills
Comfortable working in an ever-changing environment
Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work
Must have access to secure, high-speed internet for a home office
5 years of relevant auditing and/or coding experience
AHIMA/AAPC Coding Certification (RHIA, RHIT, CCS, CPC, CPC-H)