Nurse Auditor Resume Samples
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Nurse Auditor Resume Samples
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GK
G Kertzmann
Grayson
Kertzmann
63676 King Ranch
San Francisco
CA
+1 (555) 975 0555
63676 King Ranch
San Francisco
CA
Phone
p
+1 (555) 975 0555
Experience
Experience
Chicago, IL
Regional Nurse Auditor
Chicago, IL
Miller-Haag
Chicago, IL
Regional Nurse Auditor
- Conducts audits on-site and/or remotely from the Corporate office as requested by senior management
- Prepares clear and concise report of issues noted
- Participates in clinical acquisition activities as requested
- Maintain a detailed denial log for tracking and reporting purposes
- Adheres to all compliance guidelines and maintains strictest confidentiality
- Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
- Supportive of the compliance program set forth by IASIS Healthcare and demonstrated by
present
Dallas, TX
Nurse Auditor Senior
Dallas, TX
Bernier-Bergstrom
present
Dallas, TX
Nurse Auditor Senior
present
- Be a trainer for new and existing employees
- Utilize clinical expertise to plan, coordinate, conduct and report on post service audits to ensure accuracy of billed charges
- Works with Central Billing office and hospital based staff to answer clinical questions which relate to the billing process
- Writes appeal letters and submits to payers with necessary documentation for consideration
- Reviews all CMS, OIG, correspondence and adheres to all guidelines
- Coordinates with external audit companies and third party payers on all external audits (i.e. defense audits)
- Analyzing and resolving patient claims being held by billing edits that would be the responsibility of RI on the Failed claims, Failed bill, Issues, Rebill, HIM and Unbilled logs, Correct Coding Initiative, Self-Administered and other claims requiring clinical and hospital business office expertise
Education
Education
Bachelor’s Degree in Nursing Required
Bachelor’s Degree in Nursing Required
West Virginia University
Bachelor’s Degree in Nursing Required
Skills
Skills
- Strong attention to detail
- Ability to provide guidance and training to professional and technical staff in area of expertise
- Ability to clearly communicate medical information to professional practitioners and/or the general public
- Ability to recognize the appropriate style, level of detail, and message for the audience
- Excellent ability to establish, develop and manage customer relationships
- Excellent ability to identify, prioritize, resolve and / or escalate complex problems promptly
- Ability to read and interpret practice standards, professional journals, technical procedures and government standards and regulations
- Ability to execute strategy and communicate knowledge of business processes and enabling technologies, specifically in a Denial Management function
- Ability to learn new applications/software systems effectively and efficiently
- Ability to solve problems and deal with a variety of issues
8 Nurse Auditor resume templates
Read our complete resume writing guides
1
Nurse Auditor Resume Examples & Samples
- Demonstrates experience and a proven track record in denial management functions, hospital business operations, information systems, and patient accounting applications, as typically acquired in more than 5 years as a Registered Nurse, and 2 years of utilization review/case management, managed care, or comparable patient payment processing experience
- Experience developing clinical documentation auditing standards, processes, policies, procedures and service level agreements
- Experience in complex regional/ shared service environment with multiple/ matrix reporting relationships
- Detailed knowledge of medical terminology, insurance and governmental programs, regulations and billing processes, commercial/third party insurance, managed care contracts and coordination of benefits is required. Working knowledge of medical terminology and medical record coding experience is highly desirable
- Familiarity with work standards and quality control mechanisms helpful
- Knowledge of technological advancements, labor savings procedures/ processes/ equipment and other state-of-the art department-specific systems helpful
- Knowledge of Patient Management information system applications, preferably EPIC
- Ability to execute strategy and communicate knowledge of business processes and enabling technologies, specifically in a Denial Management function
- Ability to serve as a reference and coach others on key processes, policies, and procedures
- Aptitude to conceptualize, plan, and implement stated goals and objectives
- Ability to independently set and organize own work priorities for self, and successfully adapt to new priorities as part of a changing environment. Must be able to work concurrently on a variety of tasks/projects in an environment that demands a high degree of accuracy and productivity in cooperation with individuals having diverse personalities and work styles
- Ability to communicate and work with patients, physicians, associates, Sutter Health leadership, multiple direct patient care providers and others in order to expedite the patient accounting process. Strong communication skills (verbal and written) in dealing with trainees, associates, and internal/external customers
- Ability to handle heavy workloads and short deadlines in a positive manner. Adapts quickly to changing conditions, assimilating new processes into job functions and taking ownership
- Ability to comply with Sutter Health policies and procedures
- Excellent ability to identify, prioritize, resolve and / or escalate complex problems promptly
- Excellent ability to establish, develop and manage customer relationships
- Ability to learn new applications/software systems effectively and efficiently
- Demonstrated leadership skills and the ability to provide constructive feedback to team members to support continuous improvement
- Ability to effectively detect, surface and resolve conflicts among individuals and/or work groups
- Ability to communicate ideas both verbally and in writing to interact with others using on-on-one contact, formal presentations, and group discussions
- Ability to recognize the appropriate style, level of detail, and message for the audience
- Ability to positively influence others in a desired direction to achieve identified outcomes without direct lines of authority
- Ability to develop effective working relationships/ networks within and outside the organization
- Skills using spreadsheet, word processing, and basic statistical software applications, preferably Microsoft Suite
- Well-developed process design, implementation, and improvement skills
- High-level problem identification/ mitigation/ resolution and analytical skills
- Require curriculum development and adult education skills
- Requires the ability to work with and maintain confidential information
2
Remote Senior Nurse Auditor Resume Examples & Samples
- Ensure all month end responsibilities are met, e.g. Work Force Central (WFC), Paid Time Off (PTO), Billable hours
- Prefer clinical certification such as RN, LV/PN, RT, CPhT, LPTA
- Must be proficient in most Microsoft Word and Excel
- Must be able to read and interpret electronic and manual documentation generated by healthcare professionals
3
Revenue Integrity Nurse Auditor, RN Resume Examples & Samples
- Bachelors in Nursing
- Prior healthcare experience required
- Prior clinical and/or coding background preferred
- Prior HCA SSC Revenue Integrity preferred
- RN required
4
Regional Nurse Auditor Resume Examples & Samples
- Must possess a valid RN license
- Home health experience required
- Home health management experience preferred
- Medical record audit or review experience preferred
- Knowledge of home health regulations and regulatory requirements required
- Sound knowledge of clinical practice and leadership abilities
- Excellent ability to retrieve, communicate and present information both verbally and in writing
- Ability to prioritize work, meet deadlines, handle multiple projects and work under pressure in a cooperative work environment
- Ability to work collaboratively in a team environment
- Must be self-directed and motivated
- Strong attention to detail and high accuracy rate
- Knowledge of Microsoft Word and Excel is preferred
- Must be willing and able to travel 50-75% for day and overnight trips
- Conducts audits on-site and/or remotely from the Corporate office as requested by senior management
- Prepares clear and concise report of issues noted
- Participates in clinical acquisition activities as requested
- Extensive day and overnight travel required – 50-75%
5
Nurse Auditor Resume Examples & Samples
- Graduate of an accredited Registered Nursing Degree Program (ADN, Diploma, or BSN). Baccalaureate degree
- Must have clinical knowledge and be able to interpret hospital medical documentation
- Must have demonstrated knowledge of collections management
- Must be able to manage claim denial activities
- Must have a good understanding of reimbursement methodologies and terms
- Must understand payer billing requirements
- Must be able to demonstrate a working knowledge of personal computers and other standard office equipment
6
Behavioral Health Nurse Auditor Resume Examples & Samples
- Conducts Provider claim audits to determine reasonable and necessary services, thereby recovering improper payments when it is determined through the audit process that the record does not support the services billed or that the care rendered is more appropriately provided in a different care setting or level of care. Other types of audits may be performed as required by the Client
- Develops rationale for the audit decision based on the Provider’s submitted information, citing appropriate guidelines and/or applicable regulations, and enters clearly documented information in CAS / ProperPay. Follows the designated procedure for referral to a Physician Advisor if required by Client contract
- Follows CGI Federal policies and processes, completing mandatory training, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner
- Communicates timely with Team Lead required regarding illness, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues
- Complies with department standards regarding productivity and audit quality
- May be required to assist in training and/or supporting other behavioral health nurses
- Analytical Thinking
- Communication (Oral/Written)
- Health - Medicare
- Health Insurance
- Healthcare (Fed)
- Performs Well Under Pressure
7
Nurse Auditor Resume Examples & Samples
- Bachelor’s Degree in nursing and certification
- Five (5) plus year’s clinical experience in an acute care setting and three (3) plus years in a management or leadership role
- Nursing Certification/Licensure required. (RN, BSN, MSN)
- Master's Degree in Health Care or Business Administration
- Experience in a multi-hospital and/or integrated healthcare system
- Three (3) plus years working in case management or similar function in an acute care setting
- Case Management Certification
8
Nurse Auditor Resume Examples & Samples
- Analyzing and resolving patient claims being held by billing edits that would be the responsibility of RI on the Failed claims, Failed bill, Issues, Rebill, HIM and Unbilled logs, Correct Coding Initiative, Self-Administered and other claims requiring clinical and hospital business office expertise
- Interact with ancillary departments to obtain additional information needed to properly bill account based on documentation in the medical record
- Responds to payer denials that require appeal and proof of medical necessity
- Maintain a detailed denial log for tracking and reporting purposes
- Writes appeal letters and submits to payers with necessary documentation for consideration
- Coordinates with external audit companies and third party payers on all external audits (i.e. defense audits)
- Identify charging, coding, or clinical documentation issues and work with ancillary departments to resolve issues and notify appropriate leadership
- Works with Central Billing office and hospital based staff to answer clinical questions which relate to the billing process
- Reviews all CMS, OIG, correspondence and adheres to all guidelines
- Stay abreast of regulatory requirements and company compliance policies, payer requirements, significant changes and developments to ensure quality review measurements are in place at the facility
- Demonstrates an ability to be flexible, organized and function under stressful situations. Consistently demonstrates a professional, self-directed, mature, disciplined and tactful approach to department responsibilities
- Adheres to all compliance guidelines and maintains strictest confidentiality
- Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
- Supportive of the compliance program set forth by IASIS Healthcare and demonstrated by
- Attends and participates in department and hospital wide meetings
- Participates in continuing education opportunities for professional growth and development
- Other duties as assigned/required
- Knowledge of auditing concepts and principles
- Ability to use independent judgment and to manage and impart confidential information
- Advanced knowledge of medical coding and billing systems and regulatory requirements
- Knowledge of Microsoft Office programs
- Knowledge of current and developing issues and trends in medical coding procedures requirements
- Ability to clearly communicate medical information to professional practitioners and/or the general public
- Detailed knowledge of medical coding systems, procedures, and documentation requirements
- Ability to adapt and modify medical billing procedures, protocol, and data management systems to meet specific operating requirements
- Ability to provide guidance and training to professional and technical staff in area of expertise
- Skilled in data entry
- Extreme organizational skills and attention to details
- Knowledge of HMS system
- Able to develop positive relationships with managers, employees, co-workers, vendors
- Ability to prepare clear, concise reports
- Ability to read and interpret practice standards, professional journals, technical procedures and government standards and regulations
- Ability to solve problems and deal with a variety of issues
- Ability to work cooperatively with peers to contribute to the overall productivity of the team
- Physical Abilities: The work may require some physical effort, such as standing, walking, bending, sitting, lifting and carrying light folders and files. Extended periods of sitting, with continuous repetitive-motion keyboarding
- RN licensure in Colorado and direct nursing experience required
- Previous experience as a nurse auditor for an external auditing firm or third party payer preferred
- Institutional accreditation and degree obtainment will be verified upon hire
- Completes annual educational requirements
- Keeps certifications updated as needed
- Maintains regulatory requirements
9
Nurse Auditor Resume Examples & Samples
- Nursing Baccalaureate degree (BSN) from an accredited school of nursing required. Applicants without a BSN degree must actively pursue and attain a BSN within five years of hire
- Current license to practice as a registered nurse in the State of Washington
- Two years prior clinical experience
- Proven ability to be detail oriented, focused and meet production goals
- Working knowledge of EPIC medical records and a broad range of clinical experience
- Case Management and writing appeals experience
- Experience with researching and analyzing coding and charge or claim edits
10
Nurse Auditor Resume Examples & Samples
- 3+ years of directly related experience
- RN with current CO license
- Intermediate skill level with MS Office produces including: Word, Excel, Access and Power Point
- Strong analytical and decision-making skills
11
Nurse Auditor Resume Examples & Samples
- Bachelors Degree in Nursing or other clinical specialty or 6-10 years of experience in Hospital Billing, Follow-
- Must have clinical knowledge and be able to interpret hospital medical documentation (ie. EMR)
- Must have demonstrated knowledge of industry trends in Managed Care
- Work requires familiarity working with contracts and payment rules
- Must have demonstrated expertise in insurance, managed care and federal/ state coverage
- Must have working knowledge of utilization management, case management and process improvement
- 13 Must have knowledge of clinical coding and reimbursement and/or claims management
12
Nurse Auditor Resume Examples & Samples
- Previous Revenue Integrity experience highly desirable
- Must be familiar with medical record documentation standards and practices
- Must be familiar with health care insurance billing issues, and federal and state billing compliance issues for
- Ability to work independently, identify and resolve problems
- Excellent interpersonal and communication skills including ability to resolve conflicts with tact and diplomacy, work
13
Nurse Auditor Resume Examples & Samples
- Must be familiar with health care insurance billing issues, and federal and state billing compliance issues for hospitals
- Demonstrated knowledge of CPT-4 codes and ICD-9-CM codes is required. Certification as a Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H) is highly preferred
- Experience with Excel and Electronic Medical records is preferred
- Excellent interpersonal and communication skills including ability to resolve conflicts with tact and diplomacy, work with all levels of management
- Willingness to learn new skills and information including computer skills, regulatory developments
14
RN Healthcare Services Nurse Auditor Resume Examples & Samples
- Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed
- Audits for clinical gaps in care from a medical and/or behavioral perspective to ensure member needs are being met
- Coaches registered nurses and other clinical staff in appropriate clinical decision-making
- Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings to staff and leadership
- Reviews to ensure that the auditing tool aligns with provider agreement expectations
- Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications
- Adheres to departmental standards, policies, protocols
- Maintains detailed records of auditing results
- Assists HCS training team with developing training materials or job aids as needed to address findings in audit results
- Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them
- 5 - 15% local travel may be required
- 3-5 years Utilization Management or Case Management and / or managed care experience
15
Nurse Auditor Resume Examples & Samples
- Demonstrated competency in claim review and experience using billing and claims forms
- Proven competency to apply clinical expertise to ensure compliance with medical policy
- Knowledge of personal computer software, such as Microsoft Word, Excel, PowerPoint and Access
- Conducts coding audits, quality assurance assessments of claims, reviews statistical samples and analyzes for risk
- Applies nursing expertise to ensure compliance with medical policy, medical necessity guidelines and accepted standards of care
- Conducts audits to determine if claims adhere to specific provider and hospital contracts
- Ensures that medical claims, medical records and other documentation essential to proper billing is in compliance with federal regulation, company policies and industry standards
- Develops written audit findings with respect to contractual compliance, recommendations for improved contracts, and other matters identified during the audit
- Writes audit reports, as applicable. Assesses and communicates the level of risk associated with the audit issues identified in the report
- Conducts surveys of complex audit areas to define the scope and objectives of audits
- Assists in the development of overall audit plans, including comprehensive audit programs that identify specific procedures and tests designed to achieve the audit objectives
16
Revenue Integrity Nurse Auditor Resume Examples & Samples
- Excellent communication skills both verbal and written
- Able to establish good customer relationships with trust and respect
- Able to travel as needed
- Healthcare experience required, Clinical experience preferred
17
Nurse Auditor Senior Resume Examples & Samples
- Utilize clinical expertise to plan, coordinate, conduct and report on post service audits to ensure accuracy of billed charges
- Be a trainer for new and existing employees
- Proven knowledge of medical and surgical procedures and other healthcare practices
- Knowledge in reading and interpreting medical records and patient data with an ability to communicate effectively with clinical and non-clinical staff
- Ability to prepare and present clear and concise written narratives and reports
- Experience as a Nurse Auditor reviewing claims for medical necessity, coding, contract interpretation, and policy compliance
- Able to effectively interpret MCG (Milliman Care Guidelines) criteria
- Able to effectively conduct all types of audits including DRG, line by line, and level of care audits
- Deep subject matter expertise in all types of clinical audits
- Ability to mentor and train others
- Current unrestricted license as an Registered Nurse within either OR, WA, ID or UT
18
Nurse Auditor Resume Examples & Samples
- At least 5 years of experience to include time as a care giver as well as an auditor
- Recent experience in the area of auditing records to ascertain appropriate level of documentation and compliance with billing and/or legal requirements
- Previous medical record or billing audit experience preferred
19
Eh-nurse Auditor Resume Examples & Samples
- Review and analyze external auditor findings for determination of appeal
- Learn and maintain knowledge of the Exeter Hospital medical records and
- Identify, report, and communicate audited service areas at high risk for
20
Nurse Auditor Resume Examples & Samples
- 5+ years of Clinical and/or Surgical experience in a high-cost Drug / Therapy area, such as Oncology
- Associate's and/or Bachelor's Degree
- NJ Registered Nurse (RN) license and/or Licensed Practical Nurse (LPN)
