Position Highlights:

• Employee-centric: Tuition reimbursement, loan forgiveness, comprehensive major medical, dental and vision insurance, paid time off, 401(k), health and wellness offerings, monthly employee events, and more.
• Work/life: You will find support to help you manage your personal life while building a career. 
• Lifestyle: Sandusky was voted “Best Coastal Small Town in America”. You will have the opportunity to enjoy living and working in this growing area along the beautiful shores of Lake Erie.

About Firelands Health:

Our goal at Firelands Health is to be the best & preferred independent healthcare employer for the Sandusky Bay region.

Firelands Health is the area’s largest and most comprehensive resource for quality medical care. We are “big enough to care for you, and small enough to care about you”. We are locally managed and governed as a not-for-profit healthcare facility, serving the counties of Erie, Ottawa, Sandusky, and Huron, covering a regional service area with over 300,000 residents. Our mission is to provide excellent healthcare, promote community wellness, and improve the lives we serve.

Our Core ACE Values: Attitude: We choose to be positive and inclusive every day. Commitment: We are committed to exceed the expectations of those we serve. Enthusiasm: We will work passionately to make a difference.

What You Will Do:

• Responsible to distribute audit requests and denial notifications timely and accurately meeting deadline requirements. Proficient in submission of medical records to payors via various methods including mail, electronic portals, sFTP, esMD, fax and secure email. Completes data entry for both audits and denials into the tracking software, EMR/billing software, as well as, any other tracking or audit augmentation methods.
• Accountable to streamline submission processes to electronic methods whenever possible in an effort to be fiscally responsible.
• Responsible for gathering and ensuring all audit documents are in order prior to submission including the hospital/clinic records, office notes and records from outside agencies.
• Efficient with all payor software, audit/appeal tracking software tools, electronic UR software, EMR and review programs utilized in the audit & appeal process. Knowledgeable of CPT, HCPCs, DX & Px codes and revenue codes. Stays current with additions, deletions, revisions and updates as necessary. Works effectively within the audit & denials tracking tool along with other RAC team members to ensure up-to-date RAC and audit strategies are in place. Efficient with shared RAC drive operation. Participates in RAC team meetings.
• Compiles, assembles and audits documentation for RAC, CERT, OIG, QIC, FFS, Medicare/Medicaid, Commercial, Medicare Advantage and other requests prior to submission. Conducts pre and post clinical audits to review and assess the chart in order to determine if there are any discrepancies between tests and procedures ordered, performance, and charged and items that may be missing from the medical record prior to submission to the review agency. Works closely with Medical Records and ancillary departments gathering and verifying documentation is complete related to the specific audit requests. Contacts outside agencies to gather additional information to supplement and support documentation as necessary. Assists and support the timely medical record production to enable efficient management and formulation of appeals within determined deadlines.
• Ability to analyze denial issues by category and case by case basis. Create appeal templates to be used on like case types based on current industry standards. Follow industry and legal guidelines and criteria to adhere to the appeal process including but not exclusive to redeterminations, reconsiderations, dismissals, discussion periods, through all levels of appeal available based on payor and insurance type. Work in conjunction with Coding, UR, Case Management, Patient Accounts, and individual departments to achieve successful appeal strategies.
• Works effectively within the audit tracking software and RAC team to ensure that up-to-date RAC, TPE, SMRC and other audit & denial strategies are in place. Able to monitor and track audits, findings, denials and appeals to keep activity within set deadlines. Monitor records submissions and appeal outcomes to track and trend success.
• Participates in cross-training within department and actively assumes role of co-worker’s duties in times of their absence to provide continuity of coverage.
• Displays positive guest relations and demonstrates service excellence in performance of duties.

What You Will Need:

• Graduate of an accredited program of professional nursing. Possess a current RN license from the State of Ohio.
• Strong computer skills including Excel.
• Strong organization skills and the ability to multi-task.
• Minimum of 2 years healthcare experience. Strong clinical background and demonstrated critical thinking skills.
• Capable of adapting to changing environment.
• Knowledge of major insurance/Medicare terminology and benefits is beneficial.
• Strong interpersonal skills. Ability to understand and effectively communicate in both written and oral form and handle sensitive telephone and face-to-face inquiries.
• Knowledge of the Medicare program and its regulatory mandates desired. Punctual attendance at assigned work location is required.
• Ability to work in a safe and efficient manner and maintain an accident free work place, including the ability to demonstrate a working knowledge of emergency codes.