JNT Consulting LLC is seeking an experienced RN - Appeal, Clinical Documentation & Case Management
Position: RN- Appeal, Clinical Documentation and Case Management
Location: South Carolina
Responsible for improving the overall quality, accuracy and completeness of clinical documentation of patient medical records and performs responsibilities of auditor and appeal contact for RMC. Works with Physicians, Departments, and Support Staff to ensure compliance with governmental and third party payer regulations while ensuring appropriate level of care assignment for reimbursement.
This position primarily interacts with adolescents, adults and aging adults, does not provides direct patient care. All staff members must be able to demonstrate the knowledge and skill necessary to meet the physical, psycho/social, educational, safety, and related needs of the persons in the assigned work area.
• Registered Nurse with two (2) years of medical audit, utilization review, coding, or case management experience
• Two (2) years direct patient care experience.
• Knowledge of CMS guidelines, The Joint Commission standards, ORYX core measures and Interqual/Milliman criteria;
• Persistent, organized, analytical and detail oriented; Excellent interpersonal and verbal communication skills.
• Physical requirements are primarily related to the essential functions of any job. Able to Sit, Walk, Stand, Use your hands, Reach, Talk, and Hear.
• Must be able to lift or exert energy up to 10 pounds 75 % of the time and up to 25 pounds 25% of the time.
• Close vision distance or clear vision at 20 ft. or more and the ability to observe an area that can be seen to move up and down or left and right.
• Read, analyze and interpret complex scientific, clinical or business journals, financial reports or legal documents. Able to respond to sensitive inquiries or complaints from guests, regulatory agencies, staff and members of the business community.
• Has the ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to deal with concrete and abstract concepts and interpret verbal, nonverbal and written instructions.
Responsibilities:• Performs concurrent record reviews on selected admissions.
• Facilitates modification to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management staff, nursing staff, other caregivers, and HIM coding staff.
• Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve the quality of documentation and help ensure accurate HIM code/DRG assignment.
• Monitors, evaluates and reports the effectiveness of concurrent reviews and outcomes. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Audits records/bills of denials identified through various sources such as MAC, RAC, MIC, CERT, and commercial payers utilizing criteria and regulatory guidelines.
• Act as liaison with clinical departments to ensure all charges and medical documentation are appropriate and complete for Health Information Management and Patient Accounting processes.
• Responds to requests and questions of patients, staff, and third party payers with respect to hospital charges and medical documentation.
• Performs routine audits for CPRM usage of EHR resources and application of appropriate level of care criteria.
• Educates Physician offices and Clinical Departments on issues and trends identified.
• Researches new procedures/supplies and techniques to include reimbursement.
• Reviews Medicare Advisories, Transmittals, memorandums and Medicaid bulletins regarding changes in utilization and case management.
• Organizes denial management system for the Regional Medical Center.
• Appeals denials with all payer sources as appropriate.
• Additional duties/assignments as requested by the Director of CPRM and Clinical Excellence Manager.
About the Environment of the Opportunity:
The hospital has grown to a 286-bed, acute-care, medical center. The product of more than eight decades of work on the part of local physicians, community leaders and citizens, has a strong history of safeguarding the long-term health of this community.
Serving a six-county area, the medical center has a multitude of specialties and programs that offer state-of-the-art health care. It is accredited by The Joint Commission and offers a 24-hour emergency department, full range of high-quality medical services and proactive, community-wide wellness program for the area.
The medical center has experienced tremendous growth and stands ready to serve you with the latest advancements in medical technology while continuing to provide compassionate care.
This state-of-the-art facility is conveniently located near Columbia and Charleston, S.C., and is affiliated with two local schools of nursing and an allied medical technology college.
The Medical Center’s services include: comprehensive cancer treatment, inpatient psychiatry, inpatient rehabilitation, cardiac catheterization, cardiac rehabilitation, dialysis, endoscopy, health education and wellness, hospice, home health, lithotripsy, physical therapy, occupational therapy, speech therapy, pulmonary rehabilitation, nuclear medicine, diagnostic radiology (MRI, CT, mammography, ultrasound, vascular studies), radial keratotomy, obstetrics, sleep studies, sports medicine, surgery (inpatient and outpatient) and pediatrics.
The hospital is an equal opportunity employer. All individuals are entitled to equal employment opportunities regardless of race, religion, sex, national origin, age or disability, as required by state and federal law. It is committed to this philosophy and practice. All appropriate steps are taken to ensure equal opportunities in employment with respect to all personnel actions, including, but not limited to: recruiting, hiring, compensation, benefits, education and promotion/advancement opportunities.
Compensation: DOE (Depending on Experience)
Salary + Benefits
Please submit your resume in word file to: firstname.lastname@example.org and must indicate the position code: JNSC-090811 on your subject line and attach your resume.
All qualifying candidates will be interviewed by telephone for screening purposes. Succeeding steps will follow to those who will become strong candidate for the position.
NOTE: When your qualification will not match to all of the requirements of this position, your Resume will be put in our active database for future consideration of any employment opportunity. Thank you.
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