Nurse Auditor

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Job title: Nurse Auditor

Company: Evolent Health

Job description: Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference working in everything from scrubs to jeans.

Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as “Great Places to Work” in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation’s Corporate Equality Index (CEI). This index is the nation’s foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.

We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

Position Summary

The Clinical Charge Auditor is responsible for verifying the accuracy claims reimbursement, clinical significance, coding and billing in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines through medical record review. The Auditor will collaborate with a variety of business units including Market Operations, Claims, Health and Medical Management (including Medical Directors), Network Management and our external Provider community. The successful candidate must be capable of building and maintaining strong working relationships with key internal and external constituents and working effectively in a matrixed environment.

Role & Responsibilities:

  • Conduct clinical audits including but not limited to Diagnosis Related Grouper Validation (DRG), medical record billing discrepancies, and prior authorization discrepancies per policies.
  • Select claims samples for medical record reviews in accordance with pre-selection criteria, billing trends, and supporting documentation.
  • Monitor existing/emerging trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention or result in additional savings.
  • Participates in and/or leads inter-departmental process improvement initiatives. Acting as a subject matter expert with internal and external stakeholders in reference to coding, billing practices, and accuracy of assigned ICD-10 codes and DRGs.
  • Identifies compliance risks and financial opportunities based on chart reviews. Performs concurrent review of hospital bills to document unbilled, under billed, and overbilled items/services
  • Educate stakeholders on post audit findings and close audits in timely manner using audit program databases that incorporate 3M software.
  • Identify potential quality of care issues and service or treatment delays. Make referrals for follow-up as necessary.
  • Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities.
  • Actively participate in internal/external meetings, training activities and other cost and trend initiatives.
  • Identify and pursue new opportunities for cost avoidance savings that contribute to the company’s annual financial and service targets.
  • Meet deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs, and ensuring all tasks are performed to bring projects to timely closure.
  • Represent department on cross functional workgroups and projects as needed.
  • Conduct audits remotely using the EVH Payment Integrity platform and electronic medical record documentation.

Mandatory Skills:

  • Active Certified coder (RHIA, RHIT, CPC, CIC, COC or CCS) required, candidate would need to maintain active certification.
  • In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT, APR-DRG, MS-DRG codes and DRG grouping systems and Plan benefit designs.
  • Ability to travel for onsite audits as needed.
  • 3-5 years’ experience reviewing and/or auditing medical records, working in a health plan, health insurance, or similar environment.
  • Strong quantitative, analytical, interpersonal, organizational, project management, problem-solving and communication skills.
  • Ability to navigate and manage through difficult, complex conversations with positive outcomes.
  • Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems.
  • Ability to work as part of a team with a positive attitude while also able to work independently.

Preferred Skills:

  • Clinical Documentation Improvement (CDI/CDEO) certification
  • Hands-on work with complex medical and billing information preferred

Mandatory Requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 Mbps, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Preferred Requirements:

Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and national law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home.

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Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

Expected salary:

Location: Pune, Maharashtra

Job date: Fri, 06 May 2022 01:05:21 GMT

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