Nurse Auditor

The Joint Office for Compliance at UI Health Care is seeking a Nurse Auditor responsible for reviewing federal clinical denials and any necessary appeals, as well as performing compliance review work that benefits from a clinical background, such as patient status reviews, coverage determination reviews, and clinical validation of codes. This position provides education to relevant leadership, offers suggestions on documentation improvement, and develops review procedures for clinical topics.

This position is eligible for hybrid work within Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and employee travel policy when working at a remote location.

Responsibilities include:

• Performs assigned audits by researching requirements, analyzing information, and understanding operational workflow when necessary. Audits may include, but are not limited to, clinical documentation improvement (CDI) queries, level of care, quality outcomes, and CPT/ICD-10 coding.
• Reviews documentation for clinical appropriateness of diagnoses and procedures e.g., DRG validation or coverage determinations.
• Performs reviews of federal payor denials on the appropriateness of patient level of care and medical necessity and composes compelling summaries of the clinical picture of the patient to use in appeals.
• Reviews documentation for accuracy of reported quality data, for example, hospital acquired conditions, complication rates, exclusions from mortality measures, etc.
• When needed, reviews new topic areas to understand system functionality, and summarizes compliance implications and questions required to perform reviews of area.
• Identifies and resolves problems promptly.
• Demonstrates the ability to make sound and accurate decisions; supports and explains reasoning for decisions; includes appropriate people in the decision-making process.
• Communicates, typically via letter, with payers on denials.
• Communicates with providers and hospital leadership on documentation issues via written and/or verbal communication methods.
• Follows UIHC policies and procedures; completes administrative tasks correctly and timely; supports organization’s goals and values.
• Works with other JOC staff, as well as staff from other areas such as PFS, Finance, Coding Documentation Improvement (CDI), HIM, and PCD.
• Creates and provides education, as necessary, to providers and other staff on improving documentation and reducing denials.
• Reviews Medicare, Medicaid, and other claims data to ensure that charges are appropriate and supported in the medical record (forensic review).
• Contributes to the development of policies and procedures as they relate to improving processes and strengthening controls.
• Regularly reviews information to identify enhancements to the quality assurance methodology and documentation requirements. Maintains in-depth knowledge of Medicare and Medicaid billing practices, guidelines, laws, and regulations to ensure accurate Medicare and Medicaid billing.
• Participates in administrative meetings.
• Effectively analyzes problems to develop options, recommend solutions and solve complex problems.
• Generates reports of denials and outcomes.