Find & Apply For Clinical Auditor / Utilization Reviewer Jobs in Grymr-Devndle, Kentucky

JOIN TEAM TRILOGY

Weekly pay, health and dental after your first month, student loan repayment, a competitive 401(k) match, and more! Make a living while you make a difference at Trilogy Health Services - a senior living provider with the continuous goal of being the Best Healthcare Company in The Midwest.

POSITION OVERVIEW

Job Summary External Audit Support professional specializing in the submission of medical necessity for post and prepayment audits in all lines of business, plays a crucial role in ensuring compliance with regulatory standards and optimizing reimbursement for services provided. Primary responsibility will be to assess medical records, documentation, and care plans to support the necessity and appropriateness of services rendered in all lines of business. Additionally, will collaborate with interdisciplinary teams to facilitate accurate and timely submission of audit-related documentation, while adhering to industry guidelines and regulations. Roles and Responsibilities

• Conducts thorough reviews of medical records, including physician orders, nursing notes, therapy documentation, and other pertinent information to assess the medical necessity of services in order to submit our response to audits requested by any payer or external audit agency.
• Ensures timely submission of initial requests and any subsequent appeals.
• Collaborates with internal clinical support teams to relay and educate on any trends in denials.
• Supports tracking and reporting of external audits by vendor and campus to provide the status of Medical Records retrieval, submission/ acceptance of documentation, denial/appeal management, recoupment, and file closure.
• Reviews patient assessments, treatment plans, and progress notes to ensure alignment with established care standards and regulatory requirements.
• Collaborates with healthcare providers, including physicians, nurses, therapists, and other members of the healthcare team, to gather additional information and clarify documentation as needed.
• Utilizes clinical knowledge and expertise to identify potential gaps or discrepancies in documentation that may impact the reimbursement process or compliance with regulatory standards.
• Stays abreast of changes in healthcare regulations, reimbursement policies, and industry best practices related to medical necessity criteria.
• Participates in educational initiatives and training programs to enhance understanding of documentation requirements and promote compliance among staff members.
• Maintains confidentiality and integrity of patient information in accordance with HIPAA regulations and organizational policies.
• Provides support and guidance to staff members involved in the documentation and billing processes, offering education and training as needed to ensure accuracy and consistency.
• Collaborates with internal and external auditors, payers, and regulatory agencies during audits and reviews, serving as a resource and subject matter expert on medical necessity criteria and documentation standards.
• Other duties as assigned.

Qualifications Education:

Associate Degree Experience:

3-5 years Licenses and Certifications Active Registered Nurse (RN) license preferred. Active Licensed Practical Nurse (LPN) license with minimum experience of 3-5 years required. Active Therapy (OT/PT/SLP) license preferred. Physical Requirements Sitting, standing, bending, reaching, stretching, stooping, walking, and moving intermittently during working hours. Must be able to lift at least 50lbs. Must be able to maintain verbal and written communication with co-workers, supervisors, residents, family members, visitors, vendors, and all business associates outside of the health campus.

LOCATION

US-KY-Louisville Trilogy Health Services 303 N. Hurstbourne Parkway Louisville

KY BENEFITS

• Competitive salaries and weekly pay
• 401(k) Company Match
• Mental Health Support Program
• Student Loan Repayment and Tuition Reimbursement
• Health, vision, dental & life insurance kick in on the first of the month after your start date
• First time homebuyers' program
• HSA/FSA
• And so much more!

TEXT A RECRUITER

Lauren (502) 305-3565 LIFE

AT TRILOGY

Whether you're looking for a new chapter, a change of pace, or a helping hand, Trilogy is committed to being the best place that you've ever belonged. Six months of training, orientation and fun! We believe in setting our employees up for success. That's why your first six months are referred to as your "blue-badge" period - a time where you are encouraged to ask questions, ask for help when needed, and familiarize yourself with the company culture. Even when your blue badge period ends, you can rest assured that the Trilogy team will always have your back.

ABOUT TRILOGY HEALTH SERVICES

As one of Fortune's Best Places to Work in Aging Services, a certified Great Place to Work, and one of Glassdoor's Top 100 Best Companies to Work, Trilogy is proud to be an equal opportunity employer committed to helping you reach your full potential and to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy or any other protected characteristic as outlined by federal, state or local laws.

FOR THIS TYPE OF EMPLOYMENT STATE LAW REQUIRES A CRIMINAL RECORD CHECK AS A CONDITION OF EMPLOYMENT.

Qualifications:

Job Summary External Audit Support professional specializing in the submission of medical necessity for post and prepayment audits in all lines of business, plays a crucial role in ensuring compliance with regulatory standards and optimizing reimbursement for services provided. Primary responsibility will be to assess medical records, documentation, and care plans to support the necessity and appropriateness of services rendered in all lines of business. Additionally, will collaborate with interdisciplinary teams to facilitate accurate and timely submission of audit-related documentation, while adhering to industry guidelines and regulations. Roles and Responsibilities Conducts thorough reviews of medical records, including physician orders, nursing notes, therapy documentation, and other pertinent information to assess the medical necessity of services in order to submit our response to audits requested by any payer or external audit agency. Ensures timely submission of initial requests and any subsequent appeals. Collaborates with internal clinical support teams to relay and educate on any trends in denials. Supports tracking and reporting of external audits by vendor and campus to provide the status of Medical Records retrieval, submission/ acceptance of documentation, denial/appeal management, recoupment, and file closure. Reviews patient assessments, treatment plans, and progress notes to ensure alignment with established care standards and regulatory requirements. Collaborates with healthcare providers, including physicians, nurses, therapists, and other members of the healthcare team, to gather additional information and clarify documentation as needed. Utilizes clinical knowledge and expertise to identify potential gaps or discrepancies in documentation that may impact the reimbursement process or compliance with regulatory standards. Stays abreast of changes in healthcare regulations, reimbursement policies, and industry best practices related to medical necessity criteria. Participates in educational initiatives and training programs to enhance understanding of documentation requirements and promote compliance among staff members. Maintains confidentiality and integrity of patient information in accordance with HIPAA regulations and organizational policies. Provides support and guidance to staff members involved in the documentation and billing processes, offering education and training as needed to ensure accuracy and consistency. Collaborates with internal and external auditors, payers, and regulatory agencies during audits and reviews, serving as a resource and subject matter expert on medical necessity criteria and documentation standards. Other duties as assigned.

Qualifications Education:

Associate Degree Experience:

3-5 years Licenses and Certifications Active Registered Nurse (RN) license preferred. Active Licensed Practical Nurse (LPN) license with minimum experience of 3-5 years required. Active Therapy (OT/PT/SLP) license preferred. Physical Requirements Sitting, standing, bending, reaching, stretching, stooping, walking, and moving intermittently during working hours. Must be able to lift at least 50lbs. Must be able to maintain verbal and written communication with co-workers, supervisors, residents, family members, visitors, vendors, and all business associates outside of the health campus.