Nurse Auditor Resume Sample
Josephine Predovic
4104 Lockman Shoal,
Detroit,
MI
+1 (555) 927 1002
Work Experience
Regional Nurse Auditor
09/2016
-
PRESENT
Detroit, MI
- Reviews and audits medical records in association with medical claims and provider appeals for appropriate CPT, ICD-9 (ICD-10) coding and for medical necessity utilizing clinical expertise, assessment of patient and medical documentation and coding knowledge and skills
- Utilize critical thinking skills to conduct regulatory comparison with submitted claims and coding with Centers for Medicare and Medicaid (CMS), Current Procedural Terminology (CPT), National Correct Coding Initiative (NCCI), Medicaid state requirements and National Committee for Quality Assurance (NCQA)
- Ensure claims are reviewed and released within ERISA (Employee Retirement Income Security Act) standards for turnaround time
- Analyzes provider appeals for trends in inappropriate coding, fraudulent billing patterns, and opportunities for physician education. Reports and coordinates with other departments for appropriate action and educates providers on incorrect use of codes and support them in correcting documentation and billing inaccuracies
- Consults with physicians and providers offices on coding denials, edits and reviews. Coaches physicians and office staff on policies and processes to avoid future denials
- Facilitates review and creation of medical, coding and reimbursement policies for consistent and appropriate review of submitted claims, appeals and medical records
- Monitors, maintains, and initiates changes in system set up to maintain compliance with coding regulations and edits
- Administer plans consistent with benefits and Certificates of Coverage filed through State Departments of Insurance
Nurse Auditor
07/2013
-
06/2016
Los Angeles, CA
- Maintains current critical knowledge of coding required to administer auditing functions
- Gains and maintains knowledge on current/future national, regional and local healthcare coding regulations. Train and mentor new or existing staff. Provides external provider training on coding regulations and billing practices
- Demonstrates a comprehensive understanding of SelectHealth?s internal processes and procedures
- Demonstrates excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physician, office staff and other external and internal customers and departments
- Audits records/bills for accuracy following National Health Care Billing Audit guidelines. Review and audit billing, reimbursements and internal documentation to ensure adherence to technical guidelines
- Researches medical records on referred claim rejection cases and denials and ascertains the prospective appeal for the days denied by the third party payer
- Identifies cases in which an appeal is to be generated, coordinates appeal process with the physician and healthcare staff, Case Management and PFS, following departmental procedures. Documentation of activity in appeals process is documented in MIDAS following departmental procedures
- Provides management and review of all clinically based appeals to payers. Reviews medical records to ensure sufficient documentation by clinicians. Applies appropriate clinical judgement during review of denied days and medical necessity to assess whether denial can be appealed
Behavioral Health Nurse Auditor
02/2008
-
01/2013
Dallas, TX
- Responds to requests and questions of patients, staff, and third party payers with respect to hospital charges and medical documentation. Evaluates accuracy of coding and billing performance by individuals and clinical units
- Act as liaison with clinical departments to ensure all charges and medical documentation are appropriate and complete for Health Information Management and Patient Accounting processes. Prepare reports and provides individual and/or group education to physicians and others based on audit results. Assists PFS staff with claim scrubber edits
- 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
- Participates on charge capture and compliance committees, serving as expert on medical terminology and coding issues. Works collaboratively with appropriate personnel to identify and recommend strategies for process improvement and to develop and draft billing and coding policies
- Develops and coordinates educational in-services to the PFS and ancillary staff related to charging and billing issues and compliance. Reviews denial trends for documentation or charging issues
- Assists with issues related to the charge master maintenance and development
- Coordinates and schedules all patient account audits with vendors, third party agencies and review boards
- Establishes and maintains proficient level of information system knowledge
Education
Clark Atlanta University
2003 - 2007
Bachelor's Degree in Nursing Required
Professional Skills
- Strong analytical skills and strong proficiency in Excel, Lotus, Word, WordPerfect and PowerPoint
- Excellent interpersonal and communication skills including ability to resolve conflicts with tact and diplomacy,
- Excellent interpersonal and communication skills including ability to resolve conflicts with tact and diplomacy;work with all levels of management
- Excellent organizational and project management skills to permit handling of large workload
- Computer skills - navigation and edit resolution through various Web based systems. Ability to use email, Excel, Word
- Good communication skills, working with hospital departments and representing hospital with insurance company representatives and auditors
- Three years of clinical and prior audit experience required
How to write Nurse Auditor Resume
Nurse Auditor role is responsible for coding, insurance, auditing, medical, reporting, training, security, accounting, research, travel.
To write great resume for nurse auditor job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Nurse Auditor Resume
The section contact information is important in your nurse auditor resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Nurse Auditor Resume
The section work experience is an essential part of your nurse auditor resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous nurse auditor responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular nurse auditor position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Nurse Auditor resume experience can include:
- Experience working in an acute setting
- Experience in compliance and auditing in a healthcare setting
- Identify any quality of care issues, validate medical necessity of inpatient admissions, as well as any procedures performed during the stays
- Ascertain that all work products are validated for accuracy and reasonability and delivered timely
- At least five years of experience in a hospital setting, preferably cardiology, radiology, surgery or utilization
- Previous claims processing experience
Education on a Nurse Auditor Resume
Make sure to make education a priority on your nurse auditor resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your nurse auditor experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Nurse Auditor Resume
When listing skills on your nurse auditor resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical nurse auditor skills:
- Managing time effectively, performing tasks accurately and meeting set timelines
- Experience in Medical Record Charge Audit or commensurate experience
- Working knowledge of EPIC medical records and a broad range of clinical experience helpful
- Experience with researching and analyzing coding and charge or claim edits needed
- Experience researching and analyzing coding and charge or claim edits
- Clinical experience in Acute hospital setting, financial auditing, charge capture knowledge
List of Typical Experience For a Nurse Auditor Resume
1
Experience For Regional Nurse Auditor Resume
- Facilitates, communicates and resolves issues with PFS department personnel, representatives of the health care community and any external contacts (i.e. federal, state, outside vendors and third party payers) as necessary
- Working daily work queues to resolve any denials or other issues of a clinical nature
- Review inpatient coding for potential errors, verify proper assignment and sequencing of ICD-9-CM diagnoses and procedure codes
- Assist in selection of inpatient cases for review, utilizing sound clinical judgment and coding knowledge
- Identify and report any systemic, trending or workflow concerns to their manager
- Monitor daily, weekly and/or monthly reporting to monitor denials by department, by type and overturn rate
- Provides education to providers and other clinical personnel regarding denials
- Performs any special projects as requested by the Revenue Cycle Leadership
2
Experience For RN Healthcare Services Nurse Auditor Resume
- Develops rationale for the audit decision based on the Provider’s submitted information, citing appropriate guidelines and/or applicable regulations, and enters clearly documented information in CAS / ProperPay. Follows the designated procedure for referral to a Physician Advisor if required by Client contract
- Behavioral health expereince is required
- Handles all case audits, works with external auditors and the appeal vendor and/or writes and submits appeal requests
- Chairs the Denial Management Team
- Supports and promotes the mission and values of Covenant Health and the Catholic Health Ministry and the mission and values of their respective hospitals
- Reviews all Noridian, CMS, OIG, correspondence and adheres to all guidelines
3
Experience For Behavioral Health Nurse Auditor Resume
- Assures timely compliance education as requested by the Regional Compliance and Safety Officer
- Analyzes all work products and provides recommendations based on analysis and review
- Assists Manager in the monitoring of the financial performance of weekly and monthly key indicators and compliance to PFS procedure and policy by gathering accurate data
- Provides training to the CHS facilities as necessary
- Provides daily feed back on the findings of audits and analysis
- Conducts weekly telephone calls to discuss findings with the facilities
- Provides weekly summaries for management review
4
Experience For Nurse Auditor Senior Resume
- Follow proper procedure for physician referral of all potential violations
- Work with support staff for scheduling and project coordination, utilize proper reference material for clinical decision-making, including Coding Manuals, Clinics and National and Local Coding Guidelines
- Assist in researching and developing new projects, travel for additional training and on-site reviews on an as-needed basis
- Meet weekly and monthly productivity standards along with acceptable physician referral rates, follow all related CGI Federal work guidelines and Code of Ethics, and assist Team Lead when needed
- Charge Capture and Protection
5
Experience For Revenue Integrity Nurse Auditor Resume
- Denial Prevention and Management
- Hospital Leadership Audit Requests
- External Audits (Managed Care, Defense, RAC)
- Defends or supports charges disputed by third party payer audits
- Identifies and prepares charges to be corrected on accounts
- Works fluidly with Patient Financial Services and other system departments to communicate audit results
- Team Standardization & Process Improvements
6
Experience For Revenue Integrity Nurse Auditor, RN Resume
- Recommends solutions to improve charge capture accuracy
- CDM and/or Revenue Integrity Subject Matter Knowledge
- Knowledge of change management principles and process improvement methods
- Revenue Integrity work
- RCS Account Review
- Perform charge reviews by verifying billing data as compared to documentation and making corrections in Patient Accounting as needed. By analyzing charge review findings, recommendations are made to corporate Revenue Integrity Leadership, SSC Revenue Integrity Leadership, facility ancillary department directors in order to improve documentation, charging flow, and accuracy
List of Typical Skills For a Nurse Auditor Resume
1
Skills For Regional Nurse Auditor Resume
- Clinical Auditing, Case Management, and/or Utilization Review experience
- Medical, surgery or preferably ICU experience
- Demonstrated knowledge of CPT-4 codes and ICD-9-CM codes is required. Certification as a Certified
- Demonstrated knowledge of CPT-4 codes and ICD-9-CM codes is required. Certification as a Certified Professional
- Related experience in healthcare management or revenue cycle operations
- Medical claims review and chart audit experience
- Prioritizes own work based on hospital needs and CMS requirements
- Higher level auditors complete more detailed account review, have more experience, or have higher credentials
2
Skills For RN Healthcare Services Nurse Auditor Resume
- Experience in project management and/or software implementation
- Demonstrated knowledge of CPT-4 codes and ICD-9-CM codes is required
- Working knowledge of multiple healthcare applications, including but not limited to n’Thrive, GI, SSI, 3M, and CDM maintenance software tools
- Working daily workqueues to resolve any denials or other issues of a clinical nature
- Manual dexterity of hands and fingers, this includes frequent computer use and typing for documenting member care, accessing needed information, etc
- Review medical records for accuracy of payment through verification of coding and billing as determined by clinical information and appropriate guidelines
3
Skills For Behavioral Health Nurse Auditor Resume
- Five (5) years in nursing with two (2) years clinical auditing
- Be familiar and have a working knowledge of multiple computer programs: EXCEL, word processing, electronic charts
- Five years in nursing with two years clinical auditing
- Assure personal knowledge is current of: correct coding initiatives, AHA coding
- CPC or any other coding relevant coding certification
- Perform daily maintenance of billing work queues, ensuring accuracy and compliance with Medicare and other federal agency regulations
- Assists coders with clinical documentation issues and works as a liaison for charging and billing staff
- Knowledge and understanding of charge master document, case management processes, managed care system, coding and reimbursement
- Enter review findings using Customized Audit System (CAS), providing rationale and references to support decisions
4
Skills For Nurse Auditor Senior Resume
- Attends required training and completes any system-wide online training as assigned
- Knowledge of various hospital and professional fee coding and charging systems including ICD10, CPT and HCPCS as well as reimbursement systems such as CMS DRG, OPPS and PFS and all third party billing requirements
- Direct experience in Hospital Billing, Follow-Up, Collections, Denials, Utilization Management or
- Ongoing need for employee to see and read information, assess member needs, and view computer monitors
- Nursing Unit Registered Nurse
- Billing Work Queues (R1 ePARS or other)
- Background in managed care contract operations and /or billing compliance highly desired
- When identifying any data defects, escalates to manager or team lead as necessary
5
Skills For Revenue Integrity Nurse Auditor Resume
- Performs quality control audits by verifying the accuracy of entered data to ensure the integrity, completeness and proper usage of systems and data
- Attend client held meetings supporting revenue cycle processes as they pertain to your role
- Split Billing (Cosmetic, Organ Donors, Self-Audits) Charge Review
- Keeps updated on various billing rules to ensure charges that are identified in audits are split and rebilled properly
- Coordinates and facilitates clinical functions required for the patient accounting functions
- Provides educate and training to staff and physicians on identified revenue cycle compliance issues in order to prevent future issues
6
Skills For Revenue Integrity Nurse Auditor, RN Resume
- Develops yearly audit plans according to set audit findings with Team Lead/Manager
- Attend meetings/educational sessions to maintain knowledge base; maintaining credentials as applicable
- Specialized review of accounts for billing work queues
- Comprehensive knowledge of Revenue Cycle, hospital coding, and client software (e.g. Invision, EPIC, etc.)
- Act as subject matter expert for responsible areas, communicating knowledge to clients and internal staff
- Assist in optimizing revenue goals within the division
- Knowledge of RAC and other state/federal billing audit programs
- Works with Business Services management and staff to answer clinical questions which relate to the billing process
- Assist mentoring new staff members, work with IT staff to construct and refine edits as needed
7
Skills For Eh-nurse Auditor Resume
- Shift Department: SelectHealth - 5381 Green Street, Murray, UT 84123
- Frequent interactions with providers, members that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues accurately
- Perform corporate review of charging, coding, or clinical documentation and work with Corporate Revenue Integrity Leadership to provide charge review results and education
- Review HCA Regs Communications, applicable CMS transmittals, and Local Coverage Decisions (LCD). Assess impact to Revenue Integrity procedures and implement changes as needed
- ICU or Emergency room experience
- Work independently, set priorities, and manage work accurately and timely
- Regarded as a subject matter expert in the clinical, coding, and legal aspects of healthcare compliance and billing
- Maintain billing education; attend webcasts and conference calls as required
8
Skills For Remote Senior Nurse Auditor Resume
- Serve as an expert witness in legal audits as needed
- Utilize clinical knowledge and coding experience to validate accuracy of charges, resulting in accurate reimbursement and payment to providers; familiar with multiple reimbursement and payment methodologies
- Helps with the development and implementation of proactive approaches to improve and standardize overall retrospective claims and charge review processes
- Review and extract information from the various medical reports and ensure specific industry-standard codes that correspond to the services performed are billed appropriately
- Apply medical necessity guidelines based on appropriate criteria
- Maintain standards set for medical records review
9
Skills For Nurse Auditor Resume
- Licensure/Certification: Current Clinical Nurse licensure in the state of South Carolina
- Willingness to travel to other work settings essential
- Read and analyze data for specific audience
- Extract data from computer programs is essential
- CA RN License required
- The ability to extract data from computer programs is essential
- Utilize Behavioral Health clinical expertise to plan, coordinate, conduct and report on post service audits to ensure accuracy of billed charges
- EPIC proficiency and/or credentialed/certification
- Revenue Integrity Nurse Auditor
10
Skills For Regional Nurse Auditor Resume
- RN – Current Maryland State License
- Responds to ad-hoc requests and develops potential solutions to present to manager or team lead in a timely manner
- Identify root cause issues and escalate to Revenue Integrity Analyst or Manager, as appropriate
- Discusses next steps with Team Lead when previous task has been completed
- There are 2 levels within the Auditor Job Description (Professional I and II)
- Observation Hours Calculation and Carve-Out Review
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