Nurse Auditor I

Trend Health Partners is a tech-enabled payment integrity company. Our mission is to facilitate collaboration between payers and providers for mutual benefit and waste reduction, ultimately improving access to healthcare. We achieve this by aligning the common goals of payers and providers and fostering collaboration through a shared technology platform and seamless workflows.Joining TrendHealth Partners means becoming part of a dynamic, growing organization that promotes a collaborative and innovative work environment. Our comprehensive compensation package includes competitive salaries, highly valued health insurance, a 401(k) plan with employer match, paid parental leave, and more.The Nurse Auditor I’s primary responsibility is to perform medical necessity reviews of clinical documentation to determine the appropriateness of in-patient and outpatient services. The Nurse Auditor I ensures the compliance of contracts, policy, procedures, guidelines, and regulations are Well documented and properly executed into a compelling appeal argument with a 90+% overturn success rate.

ROLE AND RESPONSIBILITIES

• Independently audit clinical documentation to ensure consistent with billed services in a production environment
• Apply clinical and industry guidelines, payer P&P, and use of in-depth knowledge that supports medically necessity of services rendered
• Develop relationships with medical providers and health plans to confirm adherence to P&P, guidelines, and continuum of care.
• Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research and share with others, accordingly
• Share ideas that offer process improvements and share with team for education.

QUALIFICATIONS

• An active RN or LPN professional license in good standing
• 5 years of clinical practice
• Well-developed verbal and written communication skills coupled with recognizable organization
• Ability to effectively prioritize tasks

PREFERRED SKILLS

• Previous experience in medical auditing
• Experience in auditing or medical review
• Case Management and/or Utilization Review experience
• Experience in utilizing industry clinical guidelines

MENTAL AND PHYSICAL DEMANDS

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
• The nature of the work is sedentary, and the employee will be sitting most of the time.
• Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.
• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

RELATED DUTIES AS ASSIGNED

• This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. • Consequently, employees may be asked to perform other duties as required.
• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information.
• Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.

Originally posted on Himalayas