Remote Utilization Review Rn Jobs in Simpsonville, SC

Inspire health. Serve with compassion. Be the difference.

Job Summary

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.

• Advises departmental revenue owners and staff on proper usage of charge codes with medical record analysis.

• Reviews and applies appropriate billing guidelines, state and federal regulations, and third-party billing rules/coverage. Identifies opportunities for capturing additional revenue in accordance with these guidelines.

• Monitors daily charge capture, revenue reconciliation, late charge trending, revenue trending, and work queues for assigned departmental revenue owners for compliant charge capture detail and documentation integrity. Identifies operational trends and benchmarks.

• Monitors and works with Revenue Cycle and IT staff to resolve accounts that are not routing through the HB Revenue Cycle process.

• Validates assigned principal diagnosis, all secondary diagnoses, principal procedures and all secondary procedures and CPT/HCPCs codes.

• Develops data requirements and works with analytics groups to complete internal charge review audits for assigned clinical departments to ensure that charges are generated in accordance with established policies and timeframes.

• Assists supervisor in addressing questions from staff regarding coding and billing issues. Reviews escalated accounts and issues.

• Participates in system conversions, implementations, and upgrades. Provides coding and reimbursement revenue of all proposed build. Completes assigned tasks in a timely manner. Engages in Epic Implementation "go-live charging hub" and participates in Revenue Management Task Force. Works with CDM, clinical departments, and I/S to ensure Epic and the system build are in place for charge entry and charge capture of provided services.

• Identifies and troubleshoots charge issues and opportunities for enhancement. Supports the RI team by optimizing processes to ensure services rendered are accurately reported and reimbursed while maintaining compliance.

• Reviews departmental charge capture processes for compliance and updates documented procedures as appropriate.

• Coordinates with Department leadership, CDM team and related stakeholders on new procedures being performed to assure charges are set up appropriately and timely education is provided to those affected.

• Partner with vendors on optimization projects to complete data review, auditing, and testing.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - High School diploma or equivalent or post-high school diploma / highest degree earned.

• Experience - Five (5) years of healthcare revenue cycle experience

In Lieu Of

• In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: Associate degree and four (4) years of healthcare revenue cycle experience including two (2) years of charge description master/revenue integrity experience

• In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: Bachelor's Degree and two (2) years charge description master/revenue integrity experience.

Required Certifications, Registrations, Licenses

• Certification in one of the following: LPN, RHIT, RHIA, CCS, CPC, or CBCS.

Knowledge, Skills and Abilities

• Understanding of OPPS, IPPS, ICD10 Coding, HCPCS/CPT Coding, revenue cycle processes.

• Ability to interact with diverse groups at all levels of the organization by providing guidance and education

• Ability to understand and apply National and Local Coverage Determination to complete assigned work queues and educate facility departments routinely.

Work Shift

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Facility

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