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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical charge audits, healthcare revenue cycle management, and compliance with regulations. Proficient in utilizing evidence-based criteria for audits and assessing clinical appeal requests while effectively communicating with multidisciplinary stakeholders.
Highest-signal resume keywords
Clinical Charge AuditsHealthcare Revenue CycleEvidence-Based Utilization ReviewCurrent Coding CertificationRegistered Nurse Licensure
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical Charge AuditsHealthcare Claim Denial ProcessEvidence-Based Utilization Review CriteriaClinical Appeal AssessmentHospital Charging and CodingRegulatory AnalysisAudit ResearchMedical Necessity DecisionsDocumentation RequirementsClinical Quality Guidelines
Soft Skills
CollaborationProblem SolvingCritical ThinkingDetail OrientationWritten and Oral Communication
Tools & Technologies
Microsoft OfficeElectronic Medical Record SystemsElectronic DatabasesMicrosoft Teams
Certifications & Qualifications
Current Coding CertificationRegistered Nurse LicensureBachelor of Science in NursingMaster of Science in Nursing (Preferred)
Industry Keywords
Healthcare AuditingDenial ManagementClinical DocumentationThird-Party Claim AuditsUtilization ReviewClinical Disease ProcessesPatient AdvocacyRegulatory ComplianceHospital Insurance BillingClinical Education
About the role
Key responsibilities & impact- Consult on clinical charge audits for Intermountain Health
- Execute clinical charge audits of medical records for denials review, defense audits, disallowed charges, and retrospective reviews
- Serve as a clinical resource for Intermountain Health Revenue Cycle departments
- Maintain knowledge of laws, rules, regulations, hospital charging and coding, clinical quality, and clinical policy guidelines
- Ensure compliance and protection of information
- Manage, maintain, and communicate denial activity to stakeholders through the denial process, including medical review boards and court proceedings
- Use evidence-based utilization review criteria to determine viability for commercial and governmental insurance audits
- Assess clinical appeal requests by analyzing payer policies and Federal/State regulations
- Collaborate with multidisciplinary stakeholders during audits
- Identify and communicate denial root causes to healthcare team members
- Serve as subject matter expert for hospital charging, documentation requirements, clinical disease processes and treatment, and medical necessity decisions
- Support clinical departments with audit research and regulatory analysis
- Provide guidance on policy and procedure development, training, and clinical education to reduce clinical denials
- Maintain understanding of assigned projects, technology, products, organizational activities, and systems
- Complete ongoing education and CEU requirements to maintain licensure and certifications
Requirements
What you’ll need- Graduate of an accredited school of nursing
- Bachelor of Science in Nursing (BSN) from an accredited institution; education is verified
- Current licensure as a registered nurse required
- Current coding certification through AAPC or AHIMA
- Experience with Microsoft Office, electronic medical record systems, and electronic databases
- In-depth knowledge of the healthcare claim denial process
- Clear understanding of the healthcare revenue cycle
- Ability to use nationally recognized evidence-based utilization review criteria such as Milliman Care Guidelines (MCG) or InterQual
- Ability to assess clinical appeal requests using payer policies and Federal/State regulations
- Video phone screens and interviews through Microsoft Teams required
- Potential onsite interviews and meetings
- Must not reside or plan to reside in California, Connecticut, Hawaii, Illinois, Massachusetts, Maine, Minnesota, New York, Pennsylvania, Rhode Island, Virginia, Vermont, or Washington
- Preferred: Master of Science in Nursing (MSN), EPIC experience, clinical experience in hospital care settings or auditing experience, utilization review and/or case management experience, hospital insurance billing, third-party claim/charging audits, or healthcare auditing experience
- Skills in collaboration, problem solving, critical thinking, detail orientation, clinical judgment, written and oral communication, patient/hospital advocacy, computer literacy, efficiency, and results focus
Benefits
Comp & perks- Generous benefits package covering programs supporting wellness, health, security, connection, and engagement
- Flexible work options where approved and stated
- Remote work option
- Company equipment subject to remote work expectations
- Ongoing education and CEU requirements support for maintaining licensure and certifications