We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.
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Job Duties & Responsibilities
• Assess the treatment plan, clinical information, and medical necessity of all requested services
• Utilizes established criteria to appropriately review billed services within established timeframe required.
• Consults with medical directors and clinical staff regarding patient’s history and current care needs and whether services billed were appropriate.
• Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action.
• Telephonic follow-up with the provider’s office to request additional information as needed.
• Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit.
• Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation.
• Perform Clinical and Coding Review on Medical Claim Appeals.
• Assess and process all education and recoupment letters after Special Investigative Committee review decision.
• Facilitates provider communication and education.
• Liaisons with internal staff members.
• Perform Clinical Review and make recommendation on Audit Pass/Fail.
• Ongoing assessment for quality indicators and concerns.
Skills & Requirements
• Required Associate's Degree in Nursing or
• Technical Diploma in Vocation Nursing
• Preferred Bachelor’s Degree in Nursing
• Required LVN - Lic- Licensed Vocational Nurses Texas Board of Nursing or Nursing Licensure Compact or
• RN-Lic-Registered Nurses Texas Board of Nursing or Nursing Licensure Compact
• Preferred CPC-Cert-Cert Professional Coder Americal Academy of Professional Coders
• Required 3 years Clinical experience in the applicable field according to the license (LVN or RN)
• 4 years of Medical Auditing experience.
Job details are sourced from the employer's original posting.
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Texas Children's Hospital is a leading pediatric hospital providing comprehensive healthcare services for children.