Senior Nurse Auditor (remote work)
AllWays Health Partners

Job Info

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A career at AllWays Health Partners is for you in every way. We're a different kind of health plan - one that challenges the status quo and keeps people at the center of everything we do. Our promise as a people-first organization starts with our employees. As a member of our team, you'll be an essential part of our mission to be an invisible superhero behind a better health system. AllWays Health Partners is a proud member of Mass General Brigham, which means that you will be at the forefront of innovation with a world-renowned health care system as we harness our unique relationship to offer fresh solutions and take the complexity out of health care. Do you want to use your talents to redefine innovation, value and the customer experience in health care? If so, join AllWays Health Partners as we work together to realize our vision of creating a world where all people live healthier lives.

Under the general direction of the Manager of Recoveries, the Sr. Nurse Auditor performs accurate and timely review of medical claims for both Internal Audits as well as onsite Charge Review. Audits detailed medical claims data, clinical records, reference materials, and system information. The Sr. Nurse Auditor will be the primary point of contact for issue resolution regarding external audits between AllWays Health Partners and the provider community, as well as for clinical knowledge within the Audit team.

Essential Functions
• Sr. Nurse Auditor utilizes CPT and ICD-10 coding to review Physician claims and operative reports for coding accuracy. Additional responsibilities include the participation in a variety of projects as requested.
• The Sr. Nurse Auditor may balance internal and external work as is required by the needs of the company.
• Internal auditing functions would focus on "desktop reviews" of claims, design and quality control of future audits and other auditing related functions.
• Identify and provide analytical data on billing trends/issues and medical cost savings opportunities.
• Works with Manager of Payment Integrity to develop and implement selection methodology, and assist testing new implementations
• Assist with selection of audit criteria based on historical findings or new coding rules. Assist with the assignment and pricing of unlisted codes, and Audit related appeals. Regularly review to identify enhancement to the audit methodology and documentation requirements.
• Identify potential SIU cases, summarize findings and notify Manager of Payment Integrity of any leads, in support of next steps or escalation to outside agencies
• Serves as a coding and clinical resource for the Provider Audit team and other departments to interpret and explain coding guidelines as needed.
• Communicate and assist with training needs to co-workers and department staff as needed.
• Perform QC for less experienced auditors, and provide senior level input/research on claims challenged by the providers.
• Sr. Nurse Auditor will be required to take part in goal setting, development of projects and internal communications with other areas impacted by the outcomes of an audit.
• Work cooperatively with other departments to obtain required documentation to complete clinical notes review.
• Communicate with hospital or provider staff regarding correct coding where inconsistencies in documentation for identified services. Work with Manager of Payment Integrity for formal correspondence to providers.
• While serving as a resource and liaison between AllWays Health Partners and external providers the Sr. Nurse Auditor will investigate and verify hospital charges on paid claims against the documentation within the AllWays Health Partners members' medical record.
• The Sr. Nurse Auditor works directly with the designated hospital representative to request documentation substantiating hospital charges when applicable.
• Provide clinical interpretation and guidance to other auditors as needed.
• Accountable for delivering high quality work.
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.
• Other duties as assigned with or without accommodation.

Working Conditions and Physical Effort
• Work is normally performed in a typical office work environment.

Qualifications
Knowledge and Education

Required:
• BA/BS with 5 - 10 years related audit experience along with current LPN licnese, RN license preferred.
• Minimum of 3-5 yr. acute clinical experience required.
• Utilization Management experience in an HMO setting preferred.
• Knowledge of CPT-4 coding, ICD-10 and HCPCS.

Preferred/Desired:

• RN license with BSN preferred.

• Certified Professional Coder (CPC) certification or CCS (Certified Coding Specialist) preferred.

• Knowledge of Managed Care, medical billing, facility or physician environment preferred.

• Computer skills including data mining using Excel and/ or database programs

Experience

Required:
• 5-10 years of coding experience in a Managed Care environment, medical billing, facility or physician environment required
• Knowledge of ICD-10, CPT, HCPS, and Revenue Billing Codes.
• Utilization management

Preferred/Desired:
• Excellent communication and interpersonal skills a must.
• Ability to consistently manage multiple priorities and adapt easily in a rapidly changing environment.
• Skilled at working independently as well as in a team environment.
• Strong written and verbal communication skills, strong computer literacy, problem solving, analytical skills, diplomacy and flexibility are all a plus.

Skills/Competencies

• Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.
• Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
• Be accountable for delivering high-quality work. Act with a clear sense of ownership.
• Bring fresh ideas forward by actively listening to and working with employees and the people we serve.

Other Skills

• Access to an automobile and possess a current Massachusetts driver's license

Action
• Ability to follow up on tasks independently

Organizational Relationships/Scope
• Reports to Manager of Recoveries
• Interacts with all level of management, and cross-functional departments

EEO Statement
Our promise as a people-first organization starts with our employees. AllWays Health Partners is committed to diversity, equity, and inclusion in our workforce, internal culture, and investments. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.

Disclaimer
The above statements are intended to describe the general nature and complexity of the work being performed by personnel assigned to this classification and do not represent an exhaustive list of all tasks, duties, and responsibilities required of personnel assigned to this position.

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