Internal Recovery Audit Contractor Auditor

Memorial Hermann - Houston, TX4.0

Full-timeEstimated: $59,000 - $80,000 a year
At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

The purpose of the Internal Recovery Audit Contractor II (RAC) position is to protect the assets of the healthcare system through a timely, accurate review of records in order to assure compliance with all regulatory requirements. The intent of the record is to evaluate the patient record for medical necessity, adequacy and quality of documentation and compliance with all applicable regulatory guidelines. The underlying objective of the auditor is to assure that documentation exists to support billing and coding. The RAC Auditor II will evaluate opportunities for education around billing, compliance and quality of documentation and make recommendations to the System Executive and Directors of Care Management for the ongoing development of continuing education. In addition, the Internal RAC Auditor II will be responsible to prepare appeals and documents that will be used in the formal, legal appeal process. The role integrates and coordinates utilization management, clinical documentation and regulatory compliance and appeals management.
Job Description

Minimum Qualifications:
Licenses/Certifications:Current and valid license to practice as a Registered Nurse (ADN or BSN) in the state of Texas. Professional certification as a Case Manager preferred but not required

Experience / Knowledge / Skills:
Four or more years of clinical experience
Excellent interpersonal communication skills
Strong analytical, data management and PC skills
Current working knowledge of utilization management, case management, regulatory requirements and reimbursement.
Understanding of services available across the continuum of care
Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components
Ability to work independently and exercise sound judgment
Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:
Coordinate all activities related to the appeal process working in conjunction with hospital campuses for their consensus
Work with CMMDs to clarify questions related to the appeal
Work with CM Directors to secure approval to proceed with appeals
Work with Patient Business services to coordinate tracking and billing of appeal activity
Work with expert witnesses and legal to prepare for and present information at official hearings
Evaluate records for compliance with regulatory standards
Applies approved clinical appropriateness criteria to evaluate appropriateness of admissions and continued stays, and documents findings based on Department standards.
Ensures that all elements critical to support patient status are documented clearly in the medical record
Collaborates with campus Case Management leadership to make determinations and recommendations for appeals and billing levels of care
Refers cases and issues to campus leadership in compliance with Department protocols and follows up as indicated
Collaborates with Patient Business Services to facilitate accurate billing and claims payment
Works collaboratively and maintains active communication with other internal RAC team members to timely and appropriate decision making.
Maintains knowledge of current regulatory and compliance requirements
Identifies, addresses and works to resolve system problems impacting compliance
Escalates issues as appropriate, as defined by Department protocols
Assist in the preparation of summary reports and audit results
Collects, analyzes and addresses data to drive practice change and positively impact outcomes
Adheres to all Memorial Hermann policies, procedures and standards, within budgetary specifications, including time management, productivity and accuracy of practice
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff.
Other duties as assigned.