Nurse Specialist II, Audit

In a world where the balance of power has favored the payers and the rules of determining coverage and the processing of claims has grown complex, someone had to find a way to give providers and patients more control over their destiny to get denied and complex claims resolved. That’s why we’re here, in your corner. We’ve got the people, the expertise and the technology to resolve claims faster and continuously optimize your A/R. Your patients don’t know how to wrangle their claims or coordinate benefits. Aging A/R is piling up and you need to get as much of it as possible. But most claims are either too complex to figure out or too small to chase down, even though there are enough of them to give a much-needed boost to your bottom line.

Are you seeking an exciting opportunity to join a passionate, growing, and dynamic team of professionals who support patients? The Nurse Specialist II works with attorneys and claims representatives by reviewing and appealing claims when appropriate to overturn clinical validation and coding denials from Medicare, Medicaid, and other third-party payers. What’s Attractive to the Right Candidate? Knowtion Health is a growing firm in a growing industry. Our status as a leader in this industry means that we have the resources to invest in the business and to innovate. Our business is intensely competitive and is constantly evolving. We quickly identify new challenges and develop solutions, so you won’t simply be doing what was done last year. Our new employees are frequently pleased and surprised by how quickly we make decisions and adapt to market conditions. Knowtion Health culture is inviting and competitive, embracing challenge and celebrating accomplishment; dedicated colleagues striving to provide quality results that have lasting impact.

Reviews medical record documentation to verify clinical indicators and coding issues as related to DRG Validation Audits, Emergency Department Downgrade Audits, Inpatient Level of Care Audits, and Charge Outlier Audits, etc. Creates detailed appeal letters for denials from payer to support payment of patient claims Manages Inventory and Follow up on accounts as appropriate Reviews InterQual/Milliman, coding guidelines and/or payer medical policies related to denied procedures or services and includes criteria in appeals letter as appropriate Provides feedback to supervisor regarding issues identified for ongoing training to peers and non-clinical staff members Identifies root causes and trends to share with clients and staff Works with peers in collaboration of clinical writing situations