University of Utah Job Description
Job Summary
Responsible for conducting audits of medical necessity of services provided through a review of clinical practice standards and provided documentation. Ensures patient billing practices conform to government reimbursement guidelines by monitoring current practices, managing and documenting audit processes, developing and implementing systems to track compliance activities and providing compliance education.
Qualifications
Current licensure to practice as a Physician’s Assistant in the State of Utah and minimum three years of experience in a patient care capacity OR current licensure to practice as a Registered Nurse (BSN or APRN) in the State of Utah and minimum five years of experience working in a patient care capacity. Patient care experience may be substituted with equivalent years of experience in medical necessity review. Must be proficient with word processing, spreadsheet and related computer applications and have exemplary human relations and effective communication skills. Requires a sound knowledge of clinical practice and exceptional critical thinking and leadership abilities. Department may require coding certification (CPC, ACS, CCS-P/H, RHIA, or RHIT).
Preferences: Knowledge of utilization review and quality assurance procedures as well as experience with InterQual or Milliman and Robertson and Case Management procedures of medical necessity auditing.
This position is patient-sensitive and must fulfill all associated vaccination requirements, or be approved for an exemption, prior to the first day of work. We protect our patients, coworkers and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.
Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.
Disclaimer
This job description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to the job.
Essential Functions
1. Reviews documentation for medical necessity. 2. Teams with providers and staff to assist departments in implementing compliance practices and monitors and coordinates those activities with the departments.3. Oversees, coordinates and conducts audits on documentation, abstraction and coding to ensure compliance with University, state and federal guidelines.4. Responsible for assisting the University in preparation for regulatory audits by developing, monitoring and updating quality controls and recommending actions to maintain compliance.5. Analyzes and documents audit processes. 6. Monitors required documentation related to audit processes.7. Recommends enhancements to operating policies and procedures for compliance review.8. Maintains current knowledge regarding federal and state guidance, organizational needs and payer regulations. 9. Serves as an expert resource in compliance issue resolution.
Comments
Work Environment and Level of Frequency typically required
Nearly Continuously: Office environment.
Physical Requirements and Level of Frequency that may be required
Nearly Continuously: Sitting, hearing, listening, talking.
Often: Repetitive hand motion (such as typing), walking.
Seldom: Bending, reaching overhead.
The staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit. The individual must demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
