Internal Recovery Audit Contractor Auditor

Memorial Hermann Houston, TX
Internal Recovery Audit Contractor AuditorSystem Services SSBWJob DescriptionThe purpose of the Internal Recovery Audit Contractor I (RAC) position is to protect the assets of the healthcare system through a timely, accurate review of records in order to assure compliance with all regulatory requirements. The intent of the record is to evaluate the patient record for medical necessity, adequacy and quality of documentation and compliance with all applicable regulatory guidelines. The underlying objective of the auditor is to assure that documentation exists to support billing and coding. Additionally the RAC Auditor will evaluate opportunities for education around billing, compliance and quality of documentation and make recommendations to the System Executive and Directors of Care Management for the ongoing development of continuing education. The role integrates and coordinates utilization management, clinical documentation and regulatory compliance.

Minimum Qualifications:

Current and valid license to practice as a Registered Nurse (ADN or BSN) or LVN in the state of Texas

Professional certification as a Case Manager preferred but not required

Three or more years of clinical experience

Excellent interpersonal communication skills

Strong analytical, data management and PC skills

Current working knowledge of utilization management, case management, regulatory requirements and reimbursement.

Understanding of services available across the continuum of care

Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components

Ability to work independently and exercise sound judgment

Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of "we advance health" through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

Evaluate records for compliance with regulatory standards

Applies approved clinical appropriateness criteria to evaluate appropriateness of admissions and continued stays, and documents findings based on Department standards.

Ensures that all elements critical to support patient status are documented clearly in the medical record

Collaborates with campus Case Management leadership to make determinations and recommendations for appeals and billing levels of care

Refers cases and issues to campus leadership in compliance with Department protocols and follows up as indicated

Collaborates with Patient Business Services to facilitate accurate billing and claims payment.

Works collaboratively and maintains active communication with other internal RAC team members to timely and appropriate decision making

Maintains knowledge of current regulatory and compliance requirements

Identifies, addresses and works to resolve system problems impacting compliance.

Escalates issues as appropriate, as defined by Department protocols

Assist in the preparation of summary reports and audit results

Collects, analyzes and addresses data to drive practice change and positively impact outcomes

Adheres to all Memorial Hermann policies, procedures and standards, within budgetary specifications, including time management, productivity and accuracy of practice

Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.

Other duties as assigned.

Qualifications/CompetenciesAssociate's - Nursing - Nursing, Bachelor's - Nursing - Nursing, CR-Certified Case Manager - CCMC (Commission for Case Manager Certification), CR-Licensed Vocational Nurse (TX Board of Nursing) - TX Board of Nursing, CR-Registered Nurse (TX Board of Nursing) - TX Board of Nursing, Diploma - Nurse - Nursing, English, Years of ExperienceAssociate's - Nursing (Required), Bachelor's - Nursing (Required), Diploma - Nurse (Required)CR-Certified Case Manager - CCMC (Commission for Case Manager Certification), CR-Licensed Vocational Nurse (TX Board of Nursing) - TX Board of Nursing, CR-Registered Nurse (TX Board of Nursing) - TX Board of Nursing