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Date Added: Sat 25/07/2020

Nurse Audit Specialist / UMMS @ Linthicum, MD

Linthicum Heights, Maryland, US
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Job Type: Permanent, FullTime

What You Will Do:

The University of Maryland Medical System is a 14-hospital system with
academic, community and specialty medical services reaching every part of
Maryland and beyond. UMMS is a national and regional referral center for
trauma, cancer care, Neurocare, cardiac care, women's and children's health and
physical rehabilitation. UMMS is the fourth largest private employer in the
Baltimore metropolitan area and one of the top 20 employers in the state of
Maryland. No organization will give you the clinical variety, the support, or
the opportunities for professional growth that you ll enjoy as a member of
our team. UMMS is currently seeking a Nurse Audit Specialist for our Hunt
Valley location.

The Following is REQUIRED for this position.

Active MD State RN Licensure and four years professional nursing experience in
a patient care setting

Four (4) years professional nursing experience, with experience in a patient
care setting

Two years performing Utilization Review/Quality Assurance/Case Management

Under general supervision, conducts internal audits of hospital bills working
with external auditors to ensure that uncompensated patient revenues resulting
from audits of patient service billings (claims) are minimal. Use the
information obtained from the audit process to inform and educate UMMS
personnel concerning clinical reimbursement results and practices.

The following statements are intended to describe the general nature and level
of work being performed by people assigned to this classification. They are not
to be construed as an exhaustive list of all job duties performed by personnel
so classified.

All registered nurses working within UMMS shall follow the guidelines for
professional practice promulgated by the Maryland State Board of Nursing. Any
need for interpretation of the guidelines will be the responsibility of the
UMMS Vice President or his/her designee.


1. Plans work for self and with coworkers, including setting goals,
prioritizing work and coordinating the execution of work. Determines work
priorities and resource allocation across multiple clinical audit activities
based on interpretation of data and reports.

A. Uses a systematic process to identify departmental charges.

B. Evaluates each patient medical record reviewing specific documents relating
to patient treatment and billable charges, identifying services billed versus
services rendered.

C. Evaluates patient medical record versus the bill, noting discrepancies in
over-, under- and incorrectly billed items, correctly calculates the total
dollar amounts for each discrepancy and submits necessary documents for patient
account adjustment.

D. Negotiates with external auditors regarding billing issues.

E. Completes and submits audit documentation in a timely fashion.

F. Communicates regularly with UMMS clinical and administrative personnel to
obtain further supportive documentation for billed services beyond that which
is found in the medical record.

G. Audits predetermined amount of billing based on complexity of audit.

H. Meets with appropriate department personnel to establish methods for
obtaining support documentation.

2. Gathers and records data used for individual, team, and feedback performance
reporting. Responsible for the integrity of recorded information.

3. Communicates with representatives of external audit companies, insurance
companies, UMMS personnel, and regulatory agencies to ensure congruence with
and understanding of UMMS audit policy, process, practice and standards.

4. Provides concurrent review of charge capture prior to claim submission in
order to maximize reimbursement and reduce revenue loss through audit process.

5. Works with the Director in the identification and research of denials
received for lack of authorization and for lack of medical acuity continued
stay and corrdinates drafting of the facility s appeal responses.

A. Assists Patient Financial Services to determine the nature of the denial for
cases rejected for payment by third payor; assesses feasibility of appeal
applying Interqual criteria and M&R criteria for length of stay.

B. Researches medical records on referred claim rejection cases and denials for
which letters were received directly by Clinical Reimbursement utilizing
criteria sets. Ascertains the prospective appeal for the days denied by the
third party payer.

C. Identifies cases in which an appeal is to be generated, coordinates appeal
process with the physician and healthcare staff following departmental
procedures. Documentation of activity in appeals process is documented in MIDAS
following departmental procedures.

D. Receives notification from third party payer; seeks additional information
to be used for appeal letters from case management staff and what information
documented in the MIDAS software on the concurrent review process.

E. Develops a working relationship with the nurse reviewers coming onsite from
the larger local payers fostering improved communication. Tracks approved and
potentially deniable days on all respective members at discharge.

F. Obtains information to aid the onsite reviewers in completing chart review
post discharge when necessary. Uses onsite reviewers as a mediator in resolving
particular issues with claim resolution within their system.

G. Assists the Director in collection of data on denials and the retrieval of
reports on denied days received by the facility, identifies trends, tracks
appeal success, and provides and interprets reports of denied days statistics
from denials received to Case Management, Finance, and other hospital
departments as requested.

6. Gives feedback to other departments.

A. Meets with appropriate department and supervisory personnel to share
information obtained during the audit process to assist in the identification
of problems that result in a loss of revenue.

B. Shares clinical expertise and knowledge with the Department of Patient
Financial Services personnel to assist in the negotiations and resolution of
patient and insurance company inquires.

C. Participates in patient unit and UMMS educational programs to address
identified issues.

7. Improves work processes in an active and continuous manner. Uses improvement
tools and methods to improve individual, team and cross-departmental
performance. Bases improvements on customer requirements, data, root-cause
analysis and outcomes.

8. Keeps current on clinical practice and protocols that impact the patient
claim audit process to include insurance regulations, Medical System charging
practices and clinical therapy updates through communication with supervisor,
appropriate professional publications and conferences.

9. Communicates effectively with immediate supervisor. Provides information
regarding work progress, actions and issues in a timely manner.

10. Designs and implements special audit and education projects.

Employee Benefits

As an employee of the University of Maryland Medical System (UMMS), you will
enjoy a comprehensive benefits program designed with you and your dependents in
mind. Subject to any eligibility waiting period, all of the benefits are
available to regular full-time employees and most benefits are available to
regular part-time employees who are regularly scheduled to work twenty (20) or
more hours per week. Many benefits are provided at no cost to employees. For
others, the cost is shared between UMMS and employees.
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