Senior Nurse Auditor

Education
Bachelor's Degree in Nursing required or Bachelor's Degree Related Field of Study required

Licenses and Credentials
Registered Nurse [RN - State License] - Generic - HR Only preferred Certified Inpatient Coder [CIC] - American Academy of Professional Coders (AAPC) preferred Certified Professional Coder [CPC] - American Academy of Professional Coders (AAPC) preferred Certified Professional Coder-Hospital [CPC-H] - American Academy of Professional Coders (AAPC) preferred Certified Coding Specialist [CCS] - American Health Information Management Association (AHIMA) preferred Registered Health Information Technician [RHIT] - American Health Information Management Association (AHIMA) preferred

Experience
Auditing experience in the healthcare industry 3-5 years preferred or Auditing experience 3-5 years required

Principal Duties & Responsibilities

• Develop and perform clinical audits to support MGB's overall revenue integrity. Clinical audits ensure that the clinical documentation contained within a patient's medical record supports the items and services that appear on a patient's bill; similarly, clinical audits ensure that all items and services provided to a patient are included on a patient's bill.
• Research best practices, including implementation of new products or systems, for Revenue Integrity initiatives, and appropriately incorporates identified best practices into process design.
• Works with enterprise and/or clinical leadership to formulate strategies to lead improvement initiatives using various work processes, tools, procedures, and methodologies, including tracer audit approach, data analytics, process improvement methods, and other problem-solving approaches. Leads projects of increasing complexity (including complex systems, political, change, and organizational issues); able to work independently on business unit initiatives.
• Develop and document a clear and concise audit exceptions report when clinical documentation does not support charges included on a patient's bill or when a compliance risk is identified. Collaborate with the Compliance team to implement corrective action plans.
• Develop corrective action plans as necessary to support appropriate revenue capture, including implementing process improvement, developing standard work, and creating clinical education to enhance revenue capture and documentation.
• Utilize charge capture audit software to identify opportunities to improve charge capture and collaborate with clinical and revenue cycle teams to implement corrective action plans to secure revenue capture on the front-end (rather than through perpetual audit activity).
• Develop and implement best practice charge capture processes to support the organization's financial performance and ensure compliance with federal and state regulatory requirements.
• Works collaboratively with leadership to increase efficiencies, reduce variability, reduce errors/defects, and involve all appropriate stakeholders.
• Serves as a technical consultant to other MGB departments.
• May perform quality reviews for work completed by Clinical Nurse Auditors or Clinical Coding Auditors in the RI department.
• Provides needed continuous improvement training and education, and works closely with other RI personnel to meet education needs at all levels throughout the enterprise.
• Responsible for monitoring federal and state regulatory developments that impact revenue capture and documentation. Perform research when needed to understand and resolve complex issues rooted in revenue capture, coding, and clinical documentation.
• Conducts research to support and defend cited charges by obtaining additional documentation.
• Communicates areas of identified opportunities for revenue improvement to Revenue Integrity leadership.
• Updates internal systems used for tracking and reporting of findings, including but not limited to patient accounting systems, spreadsheets, and databases, to facilitate monthly management reporting.
• Assists in the design and implementation of effective internal controls and infrastructure to ensure accurate and complete clinical documentation and charge capture.
• Incorporates accuracy of CPT/HCPCS coding in RI initiatives to reduce compliance risk and improve alignment with payer rules and regulations.
• Support clinical documentation improvement initiatives and training to support accurate billing and coding processes to improve reimbursement.
• Demonstrates knowledge of clinical documentation requirements to identify documentation opportunities to support various payor contractual provisions.
• Maintains knowledge of contract provisions in other third-party managed care contracts. Provides subject matter expertise to finance / reimbursement to ensure data validity and accuracy in payor reimbursement models.
• For assigned projects, develops a project scope document and project plan including the gathering of information, estimates of resources required, estimated timeline for completion, background, project objectives, description of proposed approach, deliverables, and a client communication plan. Demonstrates a growing ability to develop approaches to these organizational improvement initiatives.
• Leads and facilitates assigned initiatives, in a consulting capacity, in support of organizational improvement that will drive or have direct impact on process improvements, waste reduction, and enhancing patient and/or customer satisfaction.
• Assesses organizational performance (i.e., a function, a department, a key process, etc.) to established goals and standards; recommends innovative approaches, policies, and procedures to effect continual progress toward goals and standards.
• Provides advice and consultation on "what to measure" for performance metrics. Develops process performance metrics. Documents current processes and new processes, including extended and related processes (more complex); facilitates the design of new processes and incorporates process improvement fundamentals (removing waste, hand-offs).
• Provides expertise using basic change management tools and methods to ensure the successful and sustainable implementation of improvements.
• With support from a more senior RI resource (lead, manager, senior manager, director, etc.), coaches and mentors team members and process owners to utilize a defined PDCA process improvement methodology, incorporating PI methods that ensure the use and appropriate interpretation of data for decision making.
• Provide expertise and tools to managers, leaders, etc., to develop and sustain process improvements.
• Develops effective communication methods to keep staff and others informed about revenue enhancement initiatives of the organization and department.
• Developing skills that help aid and serve as a resource to departments and business units in identifying, planning, and implementing RI improvement initiatives with alignment to system goals.
• Develops and maintains collaborative working relationships with revenue-producing departments, information technology personnel, health information management, and coding to include a forum for continuous overall process improvement and feedback.
• Assists in the development of policies and procedures to improve accuracy and completeness of clinical charge capture for both facility (hospital) and professional revenue. Provides education and training to revenue-producing departments and RI staff.
• Develops and maintains professional working relationships with internal and external stakeholders to facilitate continuous process improvement as it relates to clinical audits and findings.
• Actively pursues opportunities to become multi-skilled to serve a more diverse role in the organization, with developing skills in organizational improvement and business problem solving.
• Strong, growing base of analytical/technical, facilitative, and process improvement knowledge.
• Guides other RI Team Members in performing RI analyses, audits, and projects.
• Other duties as assigned.

Knowledge, Skills, and Abilities

• Due to its service focus and project management emphasis, this position requires strong interpersonal and communication skills, well-developed analytic and organizational skills.
• Strong oral and written communication skills
• Strong complex problem-solving and critical thinking skills required.
• Strong knowledge of clinical care processes and documentation.
• Strong character, credibility, ethics, and integrity.
• Strong organizational and time management skills.
• Ability to perform and manage clinical charge audits by comparing medical record documentation to charges captured and identify opportunities for improved revenue capture and/or compliance with regulatory requirements.
• Ability to research coding and regulatory requirements is required.
• Ability to interact and garner trust with various levels of staff in the organization, particularly management and senior leadership, by providing practical, sound, accurate, and timely support.
• Ability to review and interpret clinical data to determine whether the services are well supported in the documentation.
• Ability to interact with all levels of health care personnel and hospital/finance management.
• Ability to work independently in a role that requires flexibility in an environment that is deadline-driven.
• Ability to research applicable CMS regulations, MGB charging policies, and payer medical and reimbursement policies.
• Flexibility, innovation, and creativity are necessary characteristics of the successful candidate.
• Experience with computer software programs such as Microsoft Office Suite (PPT, Word, Excel, etc.) and Epic.
• Demonstrated success in building and maintaining collaborative work relationships, internally and externally, across a diverse set of organizations and/or functions.
• Adept at project planning/management, with the ability to effectively prioritize, delegate, and monitor.
• Individual is expected to continuously learn and apply new continuous improvement methodologies, and to spread successful innovation through the enterprise.