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Department

Job Summary

Under general supervision performs concurrent and retrospective reviews as requested by the Revenue Integrity   Director. Responsible for selected assignments based on internal or external department requests. Responsible for clinical denial review, drafting appeals, tracking data trends and root cause analysis. Responsible for revenue integrity review to identify of documentation and operational processes to minimize lost charges and denials. Responsible for supporting education to varied audiences. Collaborates with Revenue Cycle Billing, Utilization Management, Physician Advisors, Coding, Health Information Management (HIM), Patient Safety and Quality, Enterprise Compliance Services and other departments to promote the common goal of obtaining accurate and compliant billing practices as supported by the clinical documentation. Must participate in continuous education on ICD-10, medical necessity, clinical medicine, Center of Medicare and Medicaid (CMS) and other billing carriers, as well as coding guidelines and policies.

Essential Functions:

• Concurrent and/or retrospective review of designated inpatient, outpatient, and ambulatory patient records to assess for accuracy, specificity, and compliance of patient status, charges, and billing. (25%)
• Reviewing & appealing clinical denials in accordance with current medical literature, CMS regulations and individual payer contracts, policies, or provider manuals. Consolidating trends and tracking outcomes for routine Revenue Cycle reporting. Escalating findings to Revenue Cycle leadership.(40%)
• Consolidating trends and tracking denial outcomes for routine Revenue Cycle reporting. Escalating findings to Revenue Cycle leadership. (15%)
• Educating providers, coding, CDI, UM, Revenue Cycle, and other ancillary departments regarding documentation accuracy, specificity, and compliance with rules and regulations. (10%)
• Working collaboratively with clinical and non-clinical departments across the organization to support process improvement and obtaining accurate and compliant billing practices (10%)

Education:

• Associate's Degree Required
• Bachelor?s Degree Preferred

Work Experience:

• 4-6 years of experience as a nurse in a hospital environment Required and
• 4-6 years with the appropriate level of experience in one or a combination of the following medical documentation related function: clinical coding, case management, DRG coordination, physician education, Medicaid/Medicare reimbursement. Required

Licenses:

• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required
• Certification in Clinical Documentation Integrity, Coding, Utilization Management, Care Management, Auditing, Revenue Integrity, Revenue Cycle or Compliance Preferred

Knowledge, Skills and Abilities:

• Communicate effectively in written and verbal means to ensure ideas are clearly and professionally expressed and to support respectful interdepartmental collaboration.
• Demonstrates knowledge of clinical documentation, coding systems utilized for facility and professional services in all care settings (ie: ICD-10-CM, ICD-10-PCS, CPT/HCPCS), Coding Guidelines, DRG assignments, Inpatient Prospective Payment System (IPPS), Outpatient Prospective Payment System (OPPS), Charge Description Masters (CDM), Centers for Medicaid & Medicare Services (CMS) rules & regulations.
• Demonstrates knowledge of medical necessity criteria and billing requirements for establishing the correct Inpatient, Observation, Outpatient patient status in accordance with CMS and payor contracts, policies, and provider manuals. 
• Demonstrates knowledge of insurance terms, hospital billing, and professional billing terms and payment methodologies. 
• Must be able to communicate and interact tactfully with physicians and other professionals by expressing ideas clearly and concisely and addressing audiences effectively.
• Ability to read and interpret professional journals, financial reports, and legal documents as necessary.
• Ability to define problems collects and summarizes data, establish facts and draw conclusions.
• Possesses knowledge of clinical documentation and coding concepts, DRG assignments, Inpatient Prospective Payment System (IPPS) and CMS rules and regulations.
• Must also be able to demonstrate knowledge including but not limited to, value-based purchasing, bundled payments, accountable care organizations and readmission reduction program.
• Microsoft Office Excel and SharePoint
• Variety of documentation and coding programs.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver?s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado?s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.

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About Denver Health

Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.

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