As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The CRC Auditor, conducts coding and documentation quality reviews and generates responses for cases that have been denied by commercial and government payors to ensure hospital inpatient, outpatient, and pro-fee claims, were coded and billed in accordance with nationally recognized coding guidelines, standards, regulations and regulatory requirements, as well as payor and billing guidelines. The responses generated by the Auditor may include system documentation of findings and / or a formal appeal letter. The Auditor will escalate trends to CRC leadership, Conifer Quality & Performance leadership and Conifer Compliance as warranted.
The Auditor will perform analysis on clinical documentation, evidenced based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assures appropriate action is taken within appeal time frames. Communicates identified denial trends and patterns to the CRC leadership. Provides expert application of evidence based medical necessity review criteria tool. Works collaboratively to review, evaluate and improve the denial appeal process.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines and coding guidelines, evidence based medicine, community and national medical management and coding standards and protocols.
Performs reviews of accounts denied for DRG validation and DRG downgrades.
Documents in appropriate denial tracking tool (ACE). Maintains and distributes reports as needed to leadership.
Identifies payment methodology of accounts including Managed Care contract rates, Medicare and State Funded rates, Per-Diems, DRGâ��s, Outlier Payments, and Stop Loss calculations.
Collaborates with Physician Advisors and CRC leadership when documentation-specific areas of concern are identified.
Maintains expertise in clinical areas and current trends in healthcare, inpatient coding and reimbursement methodologies and utilization management specialty areas.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Effectively organizes work priorities
Demonstrates compliance with departmental safety and security policies and practices
Demonstrates critical thinking, analytical skills, and ability to resolve problems
Demonstrates ability to handle multiple assignments and carry out work independently with minimal supervision
Demonstrates quality proficiency by maintaining accuracy at unit standard key performance indicator goals
Possesses excellent written and verbal communication skills
Detail oriented and ability to work independently and in a team setting
Moderate skills in MS Excel and PowerPoint, MS Office
Ability to research difficult coding and documentation issues and follow through to resolution
Ability to work in a virtual setting under minimal supervision
Ability to conduct research regarding state/federal guidelines and applicable regulatory guidelines related to government audit processes
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE
Includes minimum education, technical training, and/or experience required to perform the job.
Completion of BSN Degree Program or three years of experience and completion of BSN within five years of employment
RN License in the State of Practice
Current working knowledge of clinical documentation and inpatient coding, discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
Completion of BSN Degree Program
CCDS certification or inpatient coding certification
Three to Five years Clinical RN Experience
Three to Five years of Clinical Documentation Integrity experience
Must have expertise with Interqual and/or MCG Disease Management Ideologies
Strong communication (verbal/written) and interpersonal skills
Knowledge of CMS regulations
Knowledge of inpatient coding guidelines
1-2 years of current experience with reimbursement methodologies
Experience preparing appeals for clinical denials related to DRG assignment.
Strong understanding of rules and guidelines, including AHAâ��s Coding Clinics, American Association of Medical Audit Specialists (AAMAS), National Commission on Insurance Guidelines and Medicare Billing Guidelines (CMS), State Funded Billing Regulations (Arizona, California, Nevada) and grievance process; working knowledge of billing codes such as RBRVS, CPT, ICD-10, HCPCS
CERTIFICATES, LICENSES, REGISTRATIONS
CCDS or other related clinical documentation specialist certification, and/or AHIMA or AAPC Coding Credential CCS, CCA, CIC, CPC or CPMA
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to lift 15-30lbs
Ability to travel approximately 10% of the time; either to client sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical record quality reviews
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
Interaction with facility HIM and / or physician advisors
Must meet the requirements of the Conifer Telecommuting Policy and Procedure
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.