Remote Utilization Review Nurse Jobs in Oak Ridge, TN

Compliance Auditor

Full Time, 80 Per Hour Pay Period, Day Shift

This position is Remote. 

Covenant Health Overview:

Covenant Health is East Tennessee’s top-performing healthcare network with 10 hospitals and over 85 outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned, not-for-profit healthcare system and the area’s largest employer with over 11,000 employees. Covenant Health is the only healthcare system in East Tennessee to be named six times by Forbes as a Best Employer. 

Position Summary: 

Performs complex professional internal auditing. Work involves compliance audit projects for Covenant Health entities as they relate to charging, coding, documentation and billing compliance. Also provides consulting services to the organization’s management and staff and may participate in requested investigations. Maintains all organizational and professional ethical standards. Works independently under limited supervision. Reports to the Compliance Audit Manager.

• Identifies and evaluates company risk areas and provides auditing procedures related to documentation coding and billing, including reviewing and analyzing findings.
• Reviews and studies all information published by the federal government, fraud alerts, legal advisory opinions, and other publications related to coding, billing and reimbursement compliance, staying abreast of current regulations.
• Performs research and analysis of charges, CPT coding, modifiers and billing processes to ensure compliance with Medicare, Medicaid guidelines and other insurance payor guidelines.
• Coordinates with appropriate parties to complete over or under payments of claim errors identified during audits in accordance with Audit Policy.
• Communicates or assists in communicating the results of audit project via written reports and/or oral presentations to physicians, clinical management, and presents as needed to related committees.
• Documents all audit activities in a designated location; reports statistics and identified problems as directed by the Audit Workflow Process and Policy.
• Assists with special projects as requested by
• Works in conjunction with health information management, patient accounting, information systems and other personnel to assist with implementation of solutions to mitigate risk.
• Under the direction of leadership, reviews and evaluates ongoing activities involved in the baseline and periodic compliance audits and compliance programs as deemed appropriate by manager.
• Advises, educates and acts as clinical/billing liaison between system-wide facility leaders, department managers and billing staff as designated by manager in relation to audit findings and process improvement initiatives.
• Works independently and demonstrates the ability to successfully locate, interpret and apply regulations with which they may be otherwise unfamiliar, and recognizes situations which necessitate supervision and guidance from leadership.
• Maintains lines of communication with Facilities/Clinics in an ongoing effort to improve the overall quality of customer service.
• Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Minimum Education:           

None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.

Minimum Experience:         

Three (3) to five (5) years’ experience in health care. Good working knowledge of healthcare billing, Medicare/Medicaid billing guidelines, and other Third-Party Payor rules and regulations. Experience in problem solving and analytical reviews. Must be knowledgeable in use of PC's, Windows, Excel and Word Processing. Must have good public relations skills.

Licensure Requirement:      

Must have and maintain RHIT, RHIA, CCS, CPC (or equivalent certification), or current TN RN License with equivalent coding experience.