PRN RN Utilization Review Audit Specialist

University of Maryland Medical System • Baltimore, MD, United States • $200k - $250k / year • 4m ago

Company Description

Renowned as the academic flagship of the University of Maryland Medical System, our Magnet-designated facility is a nationally recognized, academic medical center with opportunities across the continuum of care. Come join UMMC and discover the atmosphere where talents and ideas come together to enhance patient care and advance the science of nursing. Located in downtown Baltimore near the Inner Harbor and Camden Yards, you won’t find a more vibrant place to work!

Job Description

General Summary

Under general supervision, conducts internal audits of hospital bills working with external auditors to ensure that uncompensated patient revenues resulting from audits of patient service billings (claims) are minimal. Use the information obtained from the audit process to inform and educate UMMS personnel concerning clinical reimbursement results and practices.

Principal Responsibilities and Tasks

Plans work for self and with coworkers, including setting goals, prioritizing work and coordinating the execution of work. Determines work priorities and resource allocation across multiple clinical audit activities based on interpretation of data and reports.
Gathers and records data used for individual, team, and feedback performance reporting. Responsible for the integrity of recorded information.
Communicates with representatives of external audit companies, insurance companies, UMMS personnel, and regulatory agencies to ensure congruence with and understanding of UMMS’ audit policy, process, practice and standards.
Provides concurrent review of charge capture prior to claim submission in order to maximize reimbursement and reduce revenue loss through audit process.
Works with the Director in the identification and research of denials received for lack of authorization and for lack of medical acuity continued stay and coordinates drafting of the facility’s appeal responses.
Gives feedback to other departments.
Improves work processes in an active and continuous manner. Uses improvement tools and methods to improve individual, team and cross-departmental performance. Bases improvements on customer requirements, data, root-cause analysis and outcomes.
Keeps current on clinical practice and protocols that impact the patient claim audit process to include insurance regulations, Medical System charging practices and clinical therapy updates through communication with supervisor, appropriate professional publications and conferences.
Communicates effectively with immediate supervisor. Provides information regarding work progress, actions and issues in a timely manner.
Designs and implements special audit and education projects.

Qualifications

Education and Experience

Current active RN registration with the Maryland State Board of Nursing is required.
Four years professional nursing experience, with experience in a patient care setting and two years performing Utilization Review/Quality Assurance/Case Management responsibilities.

Knowledge, Skills and Abilities

Knowledge of hospital review procedures, third party payment, quality improvement and regulatory agency procedures and policies.
Effective oral and written communication skills required to deal with insurance companies and hospital staff.
Effective negotiating skills.
Ability to apply clinical assessment skills to the medical record audit process and extract supportive documentation.
Ability to apply patient care protocols (standardized; UMMS; TJC) to billing practices.
Demonstrated ability in use of personal computer and related software. Expertise in spreadsheets, word processing and data base management packages preferred; ability to learn these skills required.
Ability to work independently.

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