Regulatory Review Program RN
CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.
We offer the following benefits to support you and your family:
- Free Membership to our Care@Work program supporting any child care, pet care, or adult dependent needs
- Employee Assistance Program (EAP) for you and your family
- Health/Dental/Vision Insurance
- Flexible spending accounts
- Voluntary Protection: Group Accident, Critical Illness, and Identity Theft
- Paid Time Off (PTO)
- Tuition Assistance for career growth and development
- Matching Retirement Programs
- Wellness Program
Job Summary / Purpose
The CommonSpirit Regulatory Review Program (RRP) RN supports the regulatory requirements of Care Coordination activities in partnership with Revenue Cycle, Compliance, and other applicable stakeholders. This position is responsible and accountable for the auditing of patient records to identify areas of risk in order to ensure conformance with System policies and regulatory requirements, compliance to accurate medical necessity reviews, and support proper claim submission.
This position will complete scheduled, system-wide regulatory and compliance Care Coordination audits in order to achieve organizational objectives by using a systematic approach to evaluate and improve the effectiveness of risk management and quality control by completing audits, analyzing and preparing findings for further management analysis and review. This position is also responsible for case review and research in order to support a compliant and accurate claim submission process, reduce costly delays in payment, and maximize claims reimbursement. Incumbents will use professional judgment, independent analysis and critical-thinking skills to apply clinical guidelines, policies, and regulatory requirements to ensure appropriate, complete medical necessity review, claim billing status, and discharge planning requirements.
Employees are accountable for demonstrating a strong commitment to promoting quality every day by demonstrating our organizational values of: Compassion, Inclusion, Integrity, Excellence, and Collaboration.
Essential Key Job Responsibilities
- Applies knowledge of Medicare rules and regulations pertaining to compliant billing of Medicare accounts.
- ADT status determination utilizing screening tool guidelines and Intensity of Service/ Severity of Illness criteria, and completion of thorough and accurate clinical chart review.
- Conduct and complete Care Coordination regulatory and compliance audits.
- Analysis and reporting of audit findings to RRP Leadership
- Identifies potential compliance issues that require resolution prior to release for billing.
- Data collection and analysis for the purpose of identifying and tracking specific trends.
- Facilitate second level physician reviews for appropriate level of care determination.
- Documents in the electronic medical record.
- Communicate/escalate issues to appropriate stakeholders.
- Communicate appropriate level of care and release for billing.
- Cross-train to the different job functions within the department.
- Assist with new RRP RN orientation and training.
- Perform other duties as assigned by the manager including reports, PowerPoints, and in-depth case research.
- 5 years of general acute care experience required
- Familiarity with Cerner or Epic and Midas
- Care Coordination experience preferred
- Regulatory Compliance experience preferred
- Audit / analyst experience preferred
- Minimum two (2) years’ experience with denial management, claims review, clinical documentation integrity or similar role preferred
A compensation range of $73,032 - $94,950 is the reasonable estimate that CommonSpirit in good faith believes it might pay for this particular job based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.
Licenses and Certifications
- Current RN License required
- CCM or ACM, or applicable certification preferred
Required Minimum Knowledge, Skills, Abilities, and Training:
- Strong clinical background
- Knowledge and understanding of state and federal rules and regulations related to Centers for Medicare and Medicaid Services, in relationship to Medicare acute care stays.
- Working knowledge regarding confidentiality, compliance, utilization management, and case management
- Effective analytical ability in order to develop and analyze options, recommend solutions to and solve complex problems and issues
- Effective communication skills
- Strong customer service abilities to create and maintain collaborative alliances and promote teamwork
- Working knowledge of screening guidelines (IQ & MCG)
- Working knowledge of Google Work Space or Microsoft Office
- Ability to utilize spreadsheets
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CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.
CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.