Quality Nurse Auditor (Part-Time)

OrthoNebraska creates the inspired healthcare experience all people deserve by giving people a direct path to personalized care and life-enhancing outcomes. With a focus on safety and people, we set the bar high in providing high-quality care with an unmatched experience. Our team members are critical to our success and growth, and are rewarded for their dedication and hard work. IF this sounds like the type of team and environment you want to be a part of apply today!

Position Summary: Quality Nurse Auditor.

A Quality Nurse Auditor is a registered nurse responsible for reviewing patient medical records to ensure the quality of care provided aligns with established standards and regulations, identifying areas for improvement, and collaborating with healthcare teams to implement changes that enhance patient safety and outcomes by conducting comprehensive audits of clinical documentation, compliance checks, and analyzing trends to identify potential issues; requiring strong clinical expertise, attention to detail, and knowledge of quality improvement methodologies.

Position details

Position requirements

Education: Graduate of an accredited school of nursing, Associate Required, Bachelors Preferred

Licensure: Registered Nursing licensed in the State of Nebraska or eligible compact state - required

Certification: (BLS) Basic Life Support - optional

Experience:

• 5+ years clinical experience in related areas with demonstrated competence
• Demonstrated critical thinking, analytical and problem-solving skills.
• Working knowledge of Microsoft Office Suite applications, databases and spreadsheets

Required Knowledge/Skills/Abilities

• Strong understanding of CMS regulations/measures and/or willingness to learn
• Excellent analytical skills
• Proficiency in electronic medical records
• Ability to communicate effectively with healthcare team/providers while reviewing patient records to ensure compliance with Medicare guidelines and quality standards

Essential Job Functions

• Organizes, prioritizes, coordinates, and performs the elements of account auditing to verify compliance with federal, state and private regulations and eliminate false claims.
  • Audits all inpatient, outpatient and extended stay claims for accuracy and adherence to federal guidelines for this type of service prior to submission.
  • Audits all inpatient and extended stay services for appropriate diagnosis to support tests, documentation of medical necessity to support services rendered and adherence to federal guidelines, prior to submission.
  • Advise departments of services that are not meeting Medicare criteria for documentation, medical necessity and/or a non-covered service.
• Performs inpatient and outpatient chart reviews for the purpose of data abstraction and reporting of CMS Core measure data.
  • Keeps current on Core Measures data elements, data specifications and data abstraction guidelines.
  • Ensures that abstracted data is submitted to CMS according to schedule and on or before regulatory deadlines.
  • Utilizes databases for information input.
• Communicates on a regular basis with the Quality/Accreditation Manager to make recommendations regarding chart documentation and compliance with CMS Core Measures.
  • Ensure that issues identified during abstraction are researched, addressed and communicated appropriately and in a timely manner.
  • Collaborates with Quality/Accreditation Manager and nurse educators when requested to provide training and educational materials for staff to facilitate improvements where necessary.
• Monitors and evaluates statistical feedback reports.
  • Reviews incidents where OrthoNebraska fails to meet a measure and investigates cause of failure.
  • Participates as requested in recommending, implementing and monitoring improvement efforts.
  • Summarizes performance on core measures for presentation to Quality Committee
• Analyze third party payor requests and communications to document procedural deficits that reduce hospital revenue.
  • Review and monitor requests for medical record documentation for appropriateness of requested information while maintaining patient confidentiality, hospital integrity and professional standards.
• Performs independently and collaboratively with team members to meet customer needs.
  • Promotes and participates in a collaborative approach with members of various teams to achieve desired results of increased integrity, resolution of charging errors, and enhanced documentation of services rendered by department.
  • Adapts to changes in workload, completes all assignments in a timely manner and maintains quality of work.
  • Recognizes opportunities for improvement in processes.
  • Follows established hospital and unit procedures.
  • Promotes team concept through use of interpersonal skills
• Serves as a liaison between hospital departments, external audit agencies/auditors, and patients.
  • Maintains open lines of communication with all hospital department to clarify and resolve issues related to charges of services rendered.
  • Maintains up to date protocol and procedures related to processes.
  • Communicates to all customers/staff in an open professional manner.
  • Serves as link between outside agencies and hospital charge policies.
  • Supports hospital and unit objectives.
  • Maintains confidentiality.
  • Assures quality services for all customers as an auditor/consultant for hospital departments and outside agencies to research and resolve special problems
• Demonstrates continued involvement in professional growth by developing personal education objectives and participating in opportunities to assure continued adherence to professional standards and provisions of quality patient care/service and staff development.
  • Attends hospital and unit mandatory in-services.
  • Participates in continuing education to maintain competency and to keep informed of changes affecting nursing and healthcare.
  • Share knowledge and expertise by participating in in-services and patient care conferences.
  • Serves on committees within nursing and other disciplines.
  • Maintains licensure requirements and educational records.
  • Maintains up to date knowledge of internal and external policy and procedure as well as regulatory issues.
• Demonstrates problem solving abilities and promotes continuous quality improvements to ensure highest quality customer service by recommending appropriate changes to processes.
  • Participates in Performance Improvement activities.
  • Bases decisions on facts determined through appropriate research methodology.
  • Keeps logs/statistics as appropriate and directed.
  • Identifies issues and resolutions during the audit phase.
  • Recommends change to policy and procedure as indicated by research.
  • Assists in implementation of changes by providing education as needed.
  • Participates in data extraction from medical records to promote Quality Improvement initiatives.
  • Assists with reporting of data to regulatory and third-party agencies as directed and within guidelines of federal and state regulations
• Utilizes computer technology, reports, and worksheets to maintain a comprehensive database for reporting purposes.
  • Utilizes professional written and verbal skills.
  • Utilizes various databases for information input and summarization on a daily basis.
• Support and maintain confidentiality.
  • Secure and properly handle all documents and files.
  • Maintain confidentiality of all patient information, including financial, medical and personal.
• Active Participation.
  • Assist in setting team goals.
  • Actively participate in team meetings.
  • Demonstrate self-motivating skills, to complete assigned work, assist others and maintain high production levels.
  • Recognize performance improvement opportunities and take positive action to implement them.
• Miscellaneous responsibilities to include:
  • Comply with safety activities, policies and procedures and regulatory requirements such as OSHA and The Joint Commission.
  • Participate in performance improvement activities.
  • Attend and participate in department meetings.
  • Attend mandatory educational programs.
  • Follow established guidelines as stated in hospital and departmental policies and procedures.
• Employee is responsible for all other duties as assigned for which competency has been demonstrated.
• The job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee. They may change, or new ones may be assigned at any time with or without notice.

Physical requirements: This position is classified as Medium Work in the Dictionary of Occupational Titles, requiring the exertion of 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.

Employee signature/date ______________________ Manager Signature/date ________________________