Medical Review Clinical QA Auditor (RN) - Home Health & Hospice

Knowledge, Skills and Abilities Needed: Experience in conducting medical audits, investigations, reviewing and researching post service claims for aberrant billing patters, thorough review of the medical record documentation preferred. Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others. Must be able to manage multiple assignments effectively, create documentation outlining findings, QA review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members. Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding. Proficiency with CMS 1500/UB 04 forms Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations. Working knowledge of encoder Proven ability to review, analyze, and research coding issues. Reimbursement policy and/or claims software analyst experience. Familiarity with interpreting electronic medical records (EHR) Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing. Independent, out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects; leads by example. Understands processes, procedures, and workflow; and demonstrated ability to identify areas of opportunity. Demonstrated ability to consistently apply sound judgment and good effective decision making. Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals. Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external. Demonstrated ability to collaborate effectively in a variety of settings and topics. Excellent editing and proofreading skills. Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively. Excellent time management and delivers results balancing multiple priorities. Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data. Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues. Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures. Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions. Ability to create documentation outlining findings and/or documenting suggestions. Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings. Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools. Ability to be flexible and thrive in a high pace environment with changing priorities. Adaptable to applying skills to diverse operational activities to support business needs. Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives. Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams. Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment. Required and Preferred Qualifications: Current active unrestricted Nursing license in good standing required (RN required for government contract focused positions) Not currently sanctioned or excluded from the Medicare program by OIG 3+ years diversified nursing experience providing direct care in an inpatient or outpatient setting. 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company. 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. (less than 5 yrs. may be considered for internal candidates based upon demonstrated skills and results)

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