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Medical Audit Specialist RN

Recruitment #191031-UNCY-312

Introduction

 

POSITION PURPOSE:
Act as the clinical specialist to the Provider Audits staff when analyzing traditional fee for service and managed care claims related to federal and state regulations.

PRINCIPLE ACTIVITIES
*Provides clinical expertise in all Provider Audits regarding all general providers/issues.
*Performs verification of credentials of providers in conjunction with Provider Audits to ensure HCA policy requirements are met.
*Develops and maintains audit criteria for Provider Audits.
*Performs Provider Audits of billed services, including charges and documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.
*Assists Provider Audits analyst in the evaluation and interpretation of billed charges and clinical documentation to ensure all HCA policy requirements are met and services are clinically/medically appropriate.
*Develops and provides training related to issues identified by the Provider Audits staff as needed.
*Represents the Provider Audits Unit before an ALJ and in legal proceedings regarding any general provider appeals.
*Reviews audit results of providers performed by other state agencies and make Provider Audits referrals as appropriate.
*Makes a policy recommendation to the Policy Unit, as policy issues are identified during Provider Audits.
*May be required to provide expert testimony in court proceedings.
*Performs related work as required and assigned.

MEDICAL AUDIT SPECIALIST EDUCATION AND/OR EXPERIENCE:
*Current, valid RN license and 3 years clinical experience and at least 1 year experience in medical review, auditing, utilization review, compliance or regulatory work. 
*General understanding of coding principles (CPT, HCPCS, ICD-9-CM and/or DRG)

MEDICAL AUDIT SPECIALIST - PREFERENCE MAY BE GIVEN TO CANDIDATES WITH:
*SoonerCare experience
*Experience with claims review or billing
*Experience in auditing, QA/QI or utilization review
*Advanced education

Conclusion

Veteran’s preference points apply only for initial appointment in the classified service.



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