Clinical Auditor 2

Here at Savista, we enable our clients to navigate the biggest challenges in healthcare: quality clinical care with positive patient experiences and optimal financial results. We partner with healthcare organizations to problem solve and deliver revenue cycle improvement services that enable their success, support their patients, and nurture their communities, all while living our values of Commitment, Authenticity, Respect and Excellence (CARE).

Job Summary:

The Clinical Auditor 2 performs audits of medical records on behalf of hospital clients for denials review, defense audits, disallowed charges, and utilization reviews. This position requires critical thinking and judgment and must demonstrate the ability to appropriately use standard criteria such as InterQual and Milliman (MCG) in addition to criteria established by state Medicaid programs or hospital policy. Audit and analysis must be accurate and consistently ensure a high level of quality, knowledge of laws, rules, regulations and guidelines necessary to ensure compliance and protection of information.

Primary / Essential Functions:

The Primary/ essential job duties may not be exhaustive.

Clinical Staff Responsibilities:

• Performs audits of medical records to identify and/or defend charges, including:

o Defense Audits

o Patient Inquiry Audits

o Disallowed Charges

o Biller Requested Audits

• Completes analysis of records against established criteria, (e.g., InterQual, MCG, Medicare, Medicaid criteria), to determine if patient condition and/or care meets that criteria, including:

o Avoidable day studies

o Managed care, Medicare or Medicaid reconsiderations/appeals

o Medicare or Medicaid RAC appeals or other specialized Audit Appeals (e.g. CERT, ZPIC, SMRC)

• Determine, request, and obtain appropriate supporting documentation from hospital, physicians, current medical literature and patient.
• Will compose appeal letters addressing and appealing both contract issues and medically related issues
• Organizes and prioritizes multiple cases concurrently to ensure departmental workflow and case resolution.
• Enter audit findings and/or data into Client’s computer based system.
• Proficiently utilize multiple computer based systems to complete and document work (both Savista and client)
• Client based billing, Internal based billing, medical record and quality systems
• Microsoft Outlook, Word and Excel
• Function in a professional, efficient and positive manner
• Must be customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
• Will help identify issues or challenges in the department, and come up with solutions or ideas to improve
• Maintain confidentiality of patient information and abide by all HIPAA related guidelines

Competencies:

· Puts Clients First

· Drives for Results

· Understands our Business

· Thinks Innovatively

· Values Differences

· Builds Teamwork

· Gains Trust

· Communicates Effectively

· Shows Accountability

· Takes Action

· Embraces Change

· Makes Quality Decisions

Physical / Mental Demands, Environment:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Must be able to use hands to finger, handle or feel, sit, stand, walk, lift up to 20 pounds, stoop, clean, bend, and reach with hands and arms.
• Must communicate clearly in English. Requires the ability to speak, read, write, see, and hear to perform essential duties of the job. Effective and positive human relations skills are required, including confidentiality, in order to appropriately interface with staff and clients.
• Must be able to perform multiple tasks and detailed work, problem solve, reason, and perform basic mathematical calculations.

Equipment Used:

Telephone, fax, calculator, computer, monitor, printer, hardware and software packages, computer peripheral equipment i.e. mouse and keyboard; and Microsoft software.

Minimum Qualifications:

• RN/Case Management /Utilization Review/Coding or clinical certification with a BS/BA preferred otherwise equivalent years of technical experience
• 3 to 5 years of clinical experience or 3 to 5 years of clinical auditing experience in either case management, Medicare appeals, utilization review or denials management
• Knowledge of Milliman (MCG) or InterQual criteria preferred
• Experience in medical records review, claims processing or utilization/case management in a clinical practice or managed care organization
• Fundamental knowledge of Medicare/Medicaid Guidelines
• Proficiency in navigating the internet and multi-tasking with multiple electronic documentation systems simultaneously (toggling)
• Skilled with Microsoft Outlook, Word, Excel and EMR

Savista is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $28.00 to $38.00. However, specific compensation for the role will vary within the above range based on many factors including but not limited to geographic location, candidate experience, applicable certifications, and skills.

SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.

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