Denial Auditor, Utilization Review

  • Organization

  • Lutheran Health System Serv Lutheran Health System Serv

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  • Full Time

Job Description

Denial Auditor & Educator FTE 1.0 Shift:

Under the direction of the Division Director, the Denial Auditor / Department Educator is responsible for denial management as well as educating staff, physicians, and ancillary departments regarding regulatory requirements to prevent denials. Develops and implements process improvements throughout the entire revenue cycle system to reduce denials  Reconciles the Denial AR log. Participates in the Revenue Cycle Committee as well as the monthly denial AR call with Administration. Communicates with the Shared Service Center on denials and BARRT inquiries. Collaborates with physicians, ancillary departments, Administration, Shared Service staff, and others to facilitate the achievement of desired outcomes, optimize resource utilization, reduce adverse variances to the delivery of services, and assess physician quality for peer review activities. Provides guidance to HIM regarding coding and disposition questions. Responsible for new staff training regarding the utilization review process. Audits staff compliance of regulatory requirements as well as general departmental policies. Maintains current knowledge of regulatory requirements regarding documentation and reimbursement. Provides ongoing departmental education on federal and commercial payor requirements. Works closely with the department supervisor on policy recommendation and staff audit findings. Provides additional leadership support as needed in conjunction with the department Supervisor.


Minimal Acceptable Job Qualifications: Minimum of three to five years case management experience preferably with coding or denial management experience. Current IN Registered Nurse license. Competent with Excel and Microsoft Word.

Registration/Certification/Licensure: Current state Registered Nurse licensure is required for position.

Experience: Three to five years of case management experience. Coding or previous denial experience preferred.

Education: Graduation from an accredited registered nursing program. BSN preferred.

Job Knowledge & Skills:

Demonstrates working knowledge of the English language, verbal and written.

Proficient with Microsoft Office software.

Requires strong knowledge of multidisciplinary care planning, nursing scope of practice, and problem-solving.

Demonstrates an extremely high level of interpersonal and communication skills, both verbal and written, in order to interact effectively with all internal and external customers.

Requires strong analytical and organizational skills to reconcile the denial AR log and develop and implement process improvements to reduce denials.

Demonstrates ongoing understanding of federal and commercial payor practices and regulatory requirements.

Demonstrates understanding of Corporate UR policy and conducts audits to ensure compliance within the department.

Demonstrates the knowledge and understanding of intensity of service, severity of illness, and opportunities for intervention, planned course of treatment/procedures, care needs, and outcome goals.

Demonstrates an understanding of the role or payors and provides, the need for cost containment and the effect of appropriate resource utilization.

Requires independent judgment and professional responsibility to provide supervision and the constructive feedback to management and internal/external customers.  Requires the skills necessary to support department management in planning and monitoring activities within established goals and objectives.

Requires leadership, group cohesion and communication skills promoting teamwork and group achievement.

Equal Opportunity Employer

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