RN-Clinical Auditor Manager, Care Transformation - Case Management

• Creates and maintains auditing tools, procedures, and reporting for all areas of Care Transformation operations: Clinical Documentation Improvement; Utilization Management and Status Review; Case Management Standard Work. 
• Performs operational and compliance audits adhering to regulatory requirements. 
• Creates and standardizes policies, procedures and reporting for all auditing procedures. 
• Reviews patient medical record documentation related to Clinical Documentation Improvement, Utilization Management and compares against medical bills, claims and revenue reports.
• Participates in training of specific area of focus by tailoring to specific needs identified within auditing findings. 
• Utilizes auditing data, along with data analysts/liaisons, to improve risk adjustment measures and denial management processes within department. 
• Resolves inquiries from internal and external sources to reconcile accounts accurately and within compliance guidelines. 
• Ensures compliance with government and billing guidelines by reviewing and splitting or combining claims per clinical/billing guidelines. Enhances net revenue by splitting charges that should be presented on separate claims to capture entitled revenue. 
• Improves claim submissions by reviewing, researching, resolving, and trending claim issues in a timely manner. 
• Performs other duties as assigned. 

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• 7 year’s relevant experience in clinical auditing

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois 

• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional    Regulation (IDFPR) 

     
State of Work Location: Missouri 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Missouri Division of Professional Registration 

 
State of Work Location: Oklahoma 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) 

     
State of Work Location: Wisconsin 

•     Registered Nurse (RN) Issued by Compact State  
•     Or 
•     Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services