"Clinical Nurse Auditor - HB Patient Financial Services - FT Days"

The incumbent is responsible to perform review of denied claims, conducting medical records reviews with use of standardized medical review software, determining claim appealability and initiates formal written or verbal appeals with various health plans. Must have knowledge of medical terminology, various health plan products (Medicare, Medi-Cal, HMO, PPO, Managed Care, etc.) private insurance and CMS guidelines. Previous experience substantiating appeals for Trauma, Acute and Psychiatric services. Also responsible for conducting external charge defense audits requested by insurance companies in collaborating with various audit firms for the conclusion of audits. Performs additional related duties, as assigned.

Required Qualifications:

• Three years' experience working in clinical denial review and/or clinical appeal processing
• Three years of related clinical experience in an acute care setting
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
• Must possess a current California RN license
• Must demonstrate customer service skills appropriate to the job
• Knowledge of Interqual
• Five years of internal and/or external audit experience
• Familiarity of audit software packages
• Excellent written and verbal communication skills in English
• Competent knowledge and experience with Microsoft Office computer applications, i.e. Word, Excel
• Ability to maintain a work pace appropriate to the workload
• Ability to establish and maintain effective working relationships across the Health System

Preferred Qualifications:

• Knowledge of University and medical center organizations, policies, procedures and forms