Clinical Audit and Appeals Consultant, Remote UT

R150582 Job Description: The RCO Audit & Appeals RN Consultant is responsible for consulting on clinical Appeals and Audits for Intermountain Health. The Audit/Appeals RN Consultant will execute clinical audits of medical records on behalf of Intermountain hospitals and clinics for denials review, defense audits, disallowed charges, and retrospective reviews, and will serve as clinical resource for all Intermountain Health Revenue Cycle departments. Incumbent ensures a high level of knowledge of laws, rules, regulations, clinical quality and clinical policy guidelines necessary to guarantee compliance and protection of information. This role will actively manage, maintain, and communicate all levels of denial and appeal activity to stakeholders throughout the denial process up to and including medical review boards and in the court of law.Essential Functions • Uses nationally recognized evidence-based utilization review criteria (such as Milliman Care Guidelines (MCG) or InterQual to determine viability and write clinical reviews for commercial and governmental insurance audits or appeals using supporting documentation. • Assesses the appropriateness of clinical appeal requests by identifying and analyzing payer policies and Federal/State regulations. • Collaborates with multidisciplinary stakeholders during the audit or appeal process. • Identifies and communicates root causes for denials with members of the healthcare team. • Serves as a subject matter expert for documentation requirements, clinical disease processes and treatment, medical necessity decisions and appeal escalations. • Support ancillary clinical-based departments as it relates to audits and appeals by research and analysis of regulatory information. Provide guidance with policy and procedure development, training and support, and applicable clinical education focused to reduce clinical denials. • Completes data entry in the audit/appeal databases for tracking, trends, and analysis. • Develops and maintains a thorough understanding of projects and assigned functions, including utilization of technology, products, organizational activities and systems. • Completes ongoing education and CEU requirements to maintain licensure and certifications. Skills • Collaboration • Problem solving • Critical thinking • Detail-oriented • Sound clinical judgement • Effective communication (both written and oral) • Patient/hospital advocacy • Computer literacy • Efficiency oriented • Results Focused Physical Requirements: Qualifications Required: • Graduate of an accredited school of nursing. Bachelor of Science in Nursing (BSN) from an accredited institution. Education is verified • Current licensure as a registered nurse required. • Experience in Microsoft office, electronic medical record systems and electronic databases • Demonstrates in depth knowledge of the healthcare claim denial process. • Demonstrates clear understanding of the healthcare revenue cycle. Preferred: • Master of Science in Nursing (MSN) from an accredited institution. Education is verified. • EPIC experience • Demonstrated Clinical experience in specialty care settings or previous appeals experience. • Demonstrated experience in utilization review and/or case management, hospital insurance billing, third party claim audits or auditing in healthcare setting. Physical Requirements • Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess customer needs. • Frequent interactions with customers require employees to communicate as well as understand spoken information, alarms, needs, and issues quickly and accurately. • Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer, phone, and cable set-up and use. • For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles. Location: Lake Park Building Work City: West Valley City Work State: Utah Scheduled Weekly Hours: 40 The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $40.39 - $60.96 We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits package here. Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process. All positions subject to close without notice. Apply tot his job