Demand Review Nurse Auditor

POSITION SUMMARY

The Demand Review Nurse Auditor is responsible for conducting a comprehensive review of the submitted documentation to ensure that all services billed are supported by the medical records. The Nurse Auditor will oversee processing of the Demand Liability Review Packages to include preparation of counter affidavits and participation in depositions.

ESSENTIAL JOB FUNCTIONS

• Perform reviews of medical records, coding, and servicing using clinical expertise and audit tools.
• Analyze and apply appropriate CPT, ICDx and HCPCS Level II codes for reimbursement and allowances to providers using NCCI edits, Medicare guidelines and state specific fee schedules.
• Prepare a detailed code/audit report to support denial or allowance of billed charges.
• Analyze and interpret operative reports from physicians, as well as billed charges and claims from outpatient and inpatient settings.
• Review Peer Reviews detailing the denied services and forward the instructions to a bill review processor.
• Completes assignments within Client specific TAT (Turn Around Time).
• Adhere to all deadlines and state statutes.
• Adhere to Ethos Policies and Procedures and URAC standards as appropriate to job functions.
• Performs other related duties incidental to the work described herein.
• Ability to conduct counter affidavits and ability to provide testimony in depositions.

EDUCATION/LICENCES/CERTIFICATIONS

• Bachelor's Degree preferred.
• Current licensed RN or LPN unencumbered.
• Current Certified Coder Certification.

SKILLS

• Bill Review practices.
• Medical knowledge a plus.
• Strong organizational skills and excellent interpersonal skills.
• Maintains discretion and confidentiality in all aspects of performance.

EXPERIENCE

• 3-5 years medical billing coding.
• 3-5 years performing detailed nurse audits with Demand Liability and Workers' Compensation files.
• Previous experience with submission of Counter affidavits.
• Healthcare or medical administrative experience preferred.

WORKING CONDITIONS

This position works in an office environment where temperatures are constant. Frequent prolonged periods of a stationary position. Constant operation of a computer and other office productivity machinery, such as a calculator, copy machine/printer. Frequent communication via telephone and in person with clients, customers and co-workers.

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic protected by law.

A background check will be conducted, in accordance to the local state law and regulations.