ResponsibilitiesOne of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $14.3 billion in 2023. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies.
Headquartered in King of Prussia, PA, UHS has approximately 96,700 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.
The Atlantic Region CBO is seeking a dynamic and talented Clinical Documentation Improvement (CDI) Nurse.
The Clinical Documentation Improvement (CDI) Nurse provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.
Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.
Job Summary and Qualifications
The Clinical Documentation Improvement (CDI) Nurse is responsible for evaluating the appropriateness of patient charges by examining medical records, facility protocols, corporate standards, and other relevant documentation. This role involves providing charge review outcomes, developing, and coordinating educational in-services for facility staff on charging and billing issues, and analyzing denial trends to identify documentation and charging opportunities. Additionally, the analyst acts as a liaison between facility administration, the Shared Services Center, and ancillary department directors concerning charging issues, clinical documentation, and revenue opportunities.
Key Responsibilities Include:
- Review audit finding letters from third party payers to obtain a clear understanding of audited charges.
- Analyze medical records and review the charges on the UB04 and itemized bill line by line to confirm if audited charges are supported in the records. Identify any charges that need to be removed and any charges not previously billed that would need to be added to the UB04.
- Update the charge master system as needed based on charge reviews.
- Perform charge audit reviews on high dollar claims prior to billing to ensure all billed charges are supported in the medical records and to identify any missed charges.
- Evaluate patient complaints regarding billing. Confirm if the medical records support billed charges on the UB04 and provide feedback to customer service.
- Evaluate billed services against relevant Medicare NCDs and LCDs and provide detailed findings.
- Perform an audit for Medicare claims prior to billing with AICD (automated implantable cardioverter defibrillator)/Pacemakers to ensure Medicare billing criteria is supported.
- Perform other detailed audits for claims as needed to identify cosmetic and organ transplant codes and charges that need to be separated from other ancillary charges.
- Identify audit trends and provide feedback to management and to UHS acute care facilities.
- Adherence to all applicable laws, regulations and guidelines.
- Provides clinical knowledge for CBO staff and consultation to management as needed.
- Other duties as assigned.
Qualifications
Education, Training, Experience and Licenses/Registrations Required:
- Current RN license and maintained during employment in this position.
- At least 5 years of clinical experience in an acute care setting.
- CCDS certification within 2 years of hire date.
- Critical Care, Medical/Surgical or Emergency Department nursing preferred.
- Knowledge of care delivery documentation systems and related medical record documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Working knowledge of inpatient admission criteria.
- Working knowledge of Medicare reimbursement system and coding structures preferred.
- Assertive personality traits to facilitate ongoing physician communication.
Physical and Sensory Requirements:
- Ability to read, write and converse in English.
- Excellent critical thinking skills.
- Ability to communicate with patients, families, staff, physicians, support agencies, vendors and others.
- Ability to remain calm and composed under stress.
- Ability to work independently in a time-oriented environment.
- Ability to evaluate and interpret information and make independent decisions.
- Ability to understand and interpret financial data.
- Bending, lifting (5-10 lbs), grasping, fine hand coordination, pushing and pulling, prolonged standing and/or sitting.
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