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JOB DETAILS

Nurse Auditor

Job Ref: 10677

Talent Area: RN - Performance Improvement/Quality

Location:
Corporate
Houston, TX 77005

Area/Department: Corp Rev Cycle-Transact Contro

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F


Company Profile

Houston Methodist (HM) is one of the nation’s leading health systems and academic medical centers.  HM consists of five hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center and four community hospitals throughout the greater Houston metropolitan area.  HM also includes a research institute, an international business division, numerous physician practices and several free standing emergency rooms and outpatient facilities.  Overall, HM employs over 15,000 employees.   FORTUNE magazine has placed Houston Methodist on its annual list of “100 Best Companies To Work For” since 2006.  Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.


Job Summary

The Nurse Auditor will have full responsibility to audit patient charts (i.e., medical record) upon request from Payor’s on-site auditors, Patient Accounting, Risk Management, Revenue Cycle, and other network hospital entities needing completion of audit for reasons of treatment, payment or operations.  The audit is conducted to ensure that the clinical documentation contained within the patient chart supports items and services that appear on the patient’s bill, and to ensure that all items and services provided are included on the patient bill.  Where clinical documentation does not support items appearing on the bill, the Nurse Auditor will prepare a report of exceptions and offer solutions.   The Nurse Auditor will ensure complete and timely responses to the requestor of the audit.  Responses to audits may come in the form of verbal exit conferences and/or a written exchange of findings.

ICARE VALUES

System and department specific ICARE values

INTEGRITY: We are honest and ethical in all we say and do.

COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.

ACCOUNTABILITY: We hold ourselves accountable for all our actions.

RESPECT: We treat every individual as a person of worth, dignity, and value.

EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

JOB RESPONSIBILITIES

Duties and Responsibilities are cross-referenced to the hospital’s Pillars of Excellence and will be transferred to the Performance Evaluation.

PEOPLE  25%

  1.  Works fluidly with the Centralized Business Office and other system departments to communicate audit results. 
  2. Recognizes all customers, provides customer service, including full satisfaction and follow up.   This includes customers at all facilities.
  3. Works with Risk Department to research accounts

FINANCE  20%

  1. Delivers a list of exceptions needing corrective action based on audit results.
  2. Identify charges and prepares worksheet in order to split the claim for proper billing.

QUALITY/SAFETY  25%

  1. Audits and reconciles services and items included in the patient’s chart with services and items included on the patient’s bill in a timely manner.  Where exceptions are noted, suggested solutions are offered.
  2. Identifies and prepares charges to be corrected on accounts
  3. Pre-reviews Medicare accounts being audited by Government Agencies. 

SERVICE 20%

  1. Organizes and reconciles daily workdrivers to ensure accountability of all audits assigned and to ensure audits are worked in proper priority. 
  2. Recognizes that customer service and fiduciary responsibility must be balanced.
  3. Works with outside auditors to review claims to ensure charges were billed approprietly. 

GROWTH/INNOVATION 10%

  1. Makes HM management aware of audit findings and helps develp plans to keep HM compliant with payor and government standards.  
  2. Keeps updated on various billing rules to ensure charges that are identified in audits are split and rebilled properly. 
  3. Notifies management on Government audits and regulations changes.  

This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Houston Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.

EDUCATION REQUIREMENTS

Bachelor of Science in Nursing or Associates Degree in Nursing

EXPERIENCE REQUIREMENTS

Prior nursing (hospital experience) and auditing experience, 5+ years preferred

CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED

Registered Nurse (RN)

SPECIAL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

  1. Demonstrate an understanding of the clinical research revenue cycle processes, including conducting a coverage analysis through claim submission
  2. Strong customer service and analytical skills required
  3. Knowledge of CPT/HCPCS procedural coding and Charge Description Masters
  4. Experience in general healthcare billing compliance or clinical research billing compliance

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.