Government Audit Program RN Coordinator - Remote

Cedars-Sinai

Los Angeles, CA

Expired: March 24, 2023 Applications are no longer accepted.

Full-Time

Grow your career at Cedars-Sinai!

Cedars-Sinai Medical Center has been ranked the #1 hospital in California and #2 hospital in the nation by U.S. News & World Report, 2022-23. Beyond an outstanding benefit package and competitive salaries, we take pride in hiring the best, most committed employees. Our staff reflects the culturally and ethnically diverse community we serve. They are proof of our dedication to creating a multifaceted, inclusive environment that fuels innovation and the gold standard of patient care we strive for.

What will you be doing in this role:

The Government Audit Program RN Coordinator is responsible for assisting with government audits, including but not limited to, RAC., CERT, PROBE, by participating in review of identified cases and writing of response letters. Reviews denials and determines appropriates of denial based upon InterQual guidelines, professional judgment, and/or community standards.

If appeal appropriate, construct letter of appeal documenting a clinically oriented rebuttal to denied days/services based on InterQual guidelines, professional judgment, and/or community standards
Incorporates into appeal letter contractual and/or regulatory support for days/services denied as appropriate
Maintains strict adherence to all timelines to meet deadlines for submission of appeal and avoid loss of appeal due to lack of timeliness
Utilizes electronic data base to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate
Monitors for response to appeal as appropriate
Provides follow up communication when response is not received timely
Coordinates communication for second level appeals when appropriate
Makes recommendations for advance of appeal efforts to legal level
On cases where no appeal is appropriate provides documentation to support decision
Monitors, identifies, and reports on suspected or actual trends in denials
Works in collaboration with Case Management, PFS, providers, other CSMC departments and health plans to develop corrective action plans to address identified trends in reasons for denials
Monitors and reports on revenue recovery resulting from appeal efforts
Maintain knowledge of federal, state, and other regulatory agency rules and regulation including The Joint Commission, CMS, Medi-Cal etc.
Maintain current knowledge of Medicare, Medi-Cal and other third-party payor reimbursement requirements
Maintain awareness of evidenced based clinical practices
Completes retrospective UR on patients whose admit, and discharge time frames did not allow for concurrent UR as cases are identified
Identifies contact on payer side for receiving UR information as able and communicates UR information in a timely manner to avoid denial for lack of clinical information

Experience Requirements:

Four (4)+ years of Case Management / GAP in acute care setting.
Four (4)+ years Commercial/Government denials and appeals experience. (preferred)

Educational/Licenses Requirements:

Associate Degree/College Diploma

BSN Preferred

Current RN License

#Jobs

#LI-Remote