Utilization Review

Nurse Auditor

This position supports the Denial, Prevention, and Recovery Department (DPR) by providing Clinical Data Analyst and Review services. The Nurse Auditor performs appeal writing, reviews, and other tasks that may be assigned by the Denial and Prevention Director. Also serves as a contact person/liaison between auditors/external resources. Evaluates trends in denials, high risk areas and provides education.

Essential duties and responsibilities include:

• Retrieves patient medical records to compile all requested documentation in the format stipulated and within the timeframe requested by CMS.
• Tracks audit requests/appeals/due dates/correspondence and communicates with payer/auditor.
• Compiles and presents reports on behalf of the Denial & Prevention Department.
• Writes appeals, works with providers to obtain letters of medical necessity for appeal work, reviews records for medical necessity.
• Manages departmental correspondence, mail, and tracking spreadsheets.
• Cross trains to other roles within the department, in particular insurance review and case management.
• Develops front end education and training to related denials.

Education:

• Graduate of an accredited Associates or Bachelors Nursing program required. Training in Microsoft EXCEL highly preferred.

Work experience:

• At least 3 years of clinical experience. Experience with utilization management, discharge planning, and third party payors preferred. Must be computer literate and have knowledge and understanding of psycho/social needs.

Certification/License:

• Missouri or Compact State RN Licensure required.
• Case Management certification preferred.

Mental/Physical Requirements:

• Considerable mental concentration. Ability to receive and express detailed information through oral and written communications. Excellent interpersonal and organizational skills.

Working conditions:

• Hybrid remote work
• Must be able to work collaboratively with stakeholders, speaking in public at times