Overview Hospital Audit and Appeals Nurse (Hybrid) role at LCMC Health . This position reports to the Audit and Appeals Supervisor and focuses on audits and appeals for government and commercial payers to improve revenue by evaluating clinical and financial processes from patient care to final bill generation. It requires strong interpersonal, analytic and organizational skills and the ability to meet deadlines while influencing, but not directly managing, others.
Responsibilities Manage payer denials by conducting retrospective analytical review of clinical documentation to determine if an appeal is warranted in a timely manner
Exercise discretion and independent judgment when completing medical record quality audits and preparing appeal arguments with the appropriate department, relating to payer policy/procedure, contract agreements and regulatory requirements
Research and analyze the RRL (review result letters) for government and third-party payer denials related to DRG Assignment, Medical Necessity, Level of Care, and Clinical Authorizations; provide supporting documentation for audit and appeal to pursue resolution through all appeal levels; monitor pre-billing and post-billing to assist in ensuring accurate reimbursement
Follow up communication with physicians and other provider personnel to ensure documentation supports submitted charges; work with the Audit and Appeals coordinator to complete the appeals process
Collaborate with Compliance, Case Management, Coding, Patient Access, Managed Care Contracting, Central Business Office, Health Information Management, Finance and Clinical departments to resolve Audit and Appeal trends and other issues; participate in revenue cycle initiatives
Qualifications Experience: 5 to 8 years in healthcare finance, revenue cycle management, patient accounting and physician billing, coding and documentation
Education: Required bachelor’s degree in Healthcare
Licenses and Certifications Certified Professional Coder-Hospital (CPC-H) – American Academy of Professional Coders (required, entity: LCMC)
Certified Professional Coder (CPC) – AAPC (required, entity: LCMC)
Certified Coding Specialist (CCS) – CCHIIM (required, entity: LCMC)
Certified Coding Specialist – Physician-based (CCS-P) – CCHIIM (required, entity: LCMC)
Registered Nursing License – Louisiana State Board of Nursing (entity: LCMC)
Licensed Respiratory Therapist – State Board of Medical Examiners (entity: LCMC)
Skills and Abilities Knowledge of CPT/HCPCS, ICD-10 and related edits (e.g., NCCI); familiarity with EHR and health information systems; understanding of IPPS, OPPS and Managed Care; strong computer skills (MS Office: Word, Excel, PowerPoint); excellent oral and written communication; strong research and detail orientation; ability to interpret regulatory standards
Preferred: knowledge of insurance guidelines (MA, MC, Commercial, MCO, HMO); experience with case management or utilization review
Electronic Health Systems experience
Work Shift Days (United States of America)
About LCMC Health LCMC Health is an equal opportunity employer. Our people are dedicated to bringing the best possible care to every person and parish in Louisiana and beyond. We reserve the right to amend and change responsibilities as necessary.
Why join Deliver healthcare with heart
Give people a reason to smile
Bring compassion and integrity to your work
One-of-a-kind care
Collaborative and forward-thinking environment