Senior RN - Perioperative Clinical Case Auditor/Coordinator

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Department

Job Summary
Under general supervision, the Senior RN Perioperative Clinical Case Auditor/Coordinator, serves as a clinical liaison to over 100 surgeons and over 30 specialty surgical services. Executes rigorous clinical audits of surgical case orders and reconciliation of complex clinical Inpatient, elective and urgent surgical procedures, and documentation; with the aim of identifying gaps and recommends changes to clinical practices to ensure optimum care is delivered to all surgery patients, ensuring accuracy and compliance with various Hospital, State, and Insurance regulations. Ensures alignment of proper CPT codes against selected surgical procedures which benefits the overall insurance pre-authorization and reimbursement to maximize cost effective outcomes while increasing the department/hospitals overall reimbursement. Serves as a clinical educator, providing education, development and clinical feedback to the Surgeons, surgery service leaders and Surgery Schedulers regarding documentation and coding. Partners with the Providers, service leaders, and Epic Analysts to update/amend and maintain the Base Procedure List (BPL) for all surgical procedures. Provides New Products Committee with Financial/RVU (Relative Value Units) for reimbursement data and utilizes knowledge of both Nursing and administrative practices to perform charge audits while adhering to clinical guidelines to ensure best outcomes for surgical patients and increased revenue for Perioperative Services.

Essential Functions:

• Audits and Coordinates:
  * Executes rigorous clinical audits of surgical case orders and reconciliation of complex clinical Inpatient, Elective and urgent surgical procedures and documentation; with the aim of identifying gaps and recommends changes to clinical practices to ensure optimum care is delivered to all surgery patients.
  * Has independent oversight and decision-making authority to ensure alignment of proper CPT codes against selected surgical procedures which benefits the overall insurance pre-authorization and reimbursement to maximize cost effective outcomes while increasing the department and hospitals overall reimbursement.
  * Reviews all surgical case orders to determine the best alignment of Clinical Diagnosis to align with the patients LOS (Length of Stay) and accurate patient classification.
  * Ensuring surgical case orders are accurate and in compliance with various hospital, State and insurance regulations.
  * Performs data integrity and quality checks of surgical case orders to ensure adherence of industry best practices and HIPPA compliance.
  * Conducts other projects, including ad hoc audits or investigations pertaining to industry best practices, surgical case orders within Perioperative Services and connecting ancillary departments. (50%)
• Documentation and Reporting:
  * Exhibits a strong clinical background along with a thorough understanding and knowledge of the Base Procedure List (BPL) for all surgical procedures to document steps in collecting proper surgical procedures and revenue collection alignment.
  * Provides 'New Products Committee' with financial and RVU (Relative Value Units) for reimbursement data to assist with vetting, onboarding and decision making for all new product requests for the Perioperative Department.
  * Must utilize knowledge of both nursing and administrative practices to perform charge audits while adhering to clinical guidelines to ensure best outcomes for surgical patients and increased revenue for Perioperative Services.
  * Advises and steers Providers to determine surgical procedures needed for each specialty service line in alignment with the appropriate CPT code.
  * Captures data and utilizes said data to facilitate process improvement recommendations and standard work documentations and implementation while allowing for maximum billing and reimbursement along with accurate procedure selection.
  (30%)
• Collaborates and Communicates:
  * Serves as a clinical educator providing educational development and clinical feedback to the Attendings, surgery service leaders and Surgery Schedulers, regarding documentation and coding for all surgical procedures in conjunction with the patient's classification, procedures selection and CPT code assessment.
  * Reports adverse findings to Perioperative leadership for educational and learning opportunities while making recommendations for process improvements.
  * Partners with the Providers, services leaders and Epic Analysts to update, amend and maintain the Base Procedure List (BPL) for all surgical services; to include thirty specialty services.
  * Onboards, collaborates and educates new Surgeons with procedure recommendations and nomenclature that aligns with industry best practices, while maintaining the annual BPL for all procedures to support over thirty specialty services.
  * Provides ongoing attending, service leader and Surgery Scheduler education regarding surgical case orders for upcoming surgical procedures, CPT Code attachment, BPL and admissions order review.
  (20%)

Education:

• Bachelor's Degree Bachelor of Science in Nursing (BSN) Required

Work Experience:

• 6 to 7 years minimum in a clinical patient care setting with at least 5 years of experience within the Perioperative Services Department Required
• 1 to 2 years experience within a Care Management or Utilization Management RN setting preferred.
• At least 1-year experience in an AAPC/RN coding environment preferred.

Licenses:

• CCS - Certified Coding Specialist - AHIMA - American Health Information Management Association (preferred)
• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required
• BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required

Knowledge, Skills and Abilities:

• Ability to navigate Excel, EPIC, Microsoft Office. AAPC Coding, Encoder and Data Abstraction Software.
• Ability to conduct clinical reviews of surgical procedures in alignment with CPT codes.
• Demonstrated ability to perform statistical analyses of clinical data.
• Ability to perform audits under general supervision, write technical audit reports, and make oral presentations to management and executive leadership.
• Knowledge of AAPC Coding, Encoder and Data Abstraction Software.
• Ability to conduct education and training to Attending, Surgical Service Leaders and Surgery Schedulers.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.