Core Competencies

• Ensures other requirements from a regulatory perspective such as delivery of the “Medicare Important Message” are met.
  
  
• Ensures all other clinical documents meet regulatory requirements as it relates to date, time and signature.
  
  
• Performs concurrent and retrospective review of Medicare and MediCal and other payors patient’s electronic and paper charts for correct patient status and appropriate admissions transfer and discharge physician orders.
  
  
• Verifies billing system for correct status prior to bill being approved and submission of daily adjudication reports.
  
  
• Applies appropriate clinical criteria (i.e. MCG) when reviewing medical records either concurrently or retrospectively.
  
  
• Works collaboratively with other hospital departments regarding ongoing employee education for correct data entry of ADT orders within the Medical Center.
  
  
• Understands the responsibilities of the Physician Advisors as the first and second level professional review organization within the Medical Center.
  
  
• Acts as a change agent by recognizing patterns and identifying opportunities for interdepartmental process improvement.
  
  
• Identifies and refers accounts meeting established criteria to the Utilization Review Committee.
  
  
• Documents audit finding such as: correct account status; level of care changes; etc., if applicable, on the Billing Audit form.
  
  
• Assists with RAC preparation.
  
  
• Assists in gathering documentation necessary to respond to the initial data requests and any subsequent appeals.
  
  
• Participates in department and hospital Performance Improvement (PI) activities.
  
  

Education

Experience

License / Certification Requirements

Compensation Range 

$48.77 - $81.51 / Hour