Job Description
The Quality Utilization Nurse Auditor reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Audit Role and Responsibilities:
- Assures timely review of clinicals as outlined by current policy and payor guidelines and ensures staff are performing accurate and complete medical assessment of patient cases:
- Performing random Audit of Payor Specialist work product
- Calculating Scores based on findings in Audit
- Providing timely feedback to staff for continued improvement and compliance with current policies and payor guidelines
- Completes all necessary documentation to support audit work
- Ensures that all quality audits are completed accurately, objectively, and in a timely manner
- Communicates audit findings and staff scores to management to assist in the annual performance evaluation process
- Documenting and maintaining documentation records for staff development purposes.
- Partner with Quality Utilization Leadership to mentor Clinical Quality Utilization Specialist and Payor Specialist on issues related to utilization review and payor specifications.
- Identify and escalate trends in issues with process and payors to appropriate leadership for resolution.
- Provide feedback to Quality Utilization leadership on team member performance to assist in annual performance evaluation.
- Identify and report denials trends to Managed Care and Clinical Quality and Documentation Leadership for concurrent level of care denials.
- Actively participates in the following:
- Coordinates audit schedule to ensure compliance with quality audit procedures for staff
- Completes all supporting information and documentation required for individual and departmental reporting
- Produces reports on individual quality scorecards as required by Leadership
- Is involved in providing input to Revenue Cycle leadership on new department policies and procedures
- Tracks individual, department, and division-wide quality audit performance in defined quality tools
- Perform root cause denials review to be shared with Managed Care and Clinical Quality Leadership
- Consistently communicates quality audit results to Manager/Director
- Complies with the current quality sign off and documentation procedure for all Quality Auditors.
- Other:
- Participates on departmental and hospital committees and task forces as assigned.
- Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPAA requirements and Personal Rules of Conduct.
- Works with Medical Leadership throughout the system to resolve issues.
Qualifications
Required:
- Registered Nurse in the State of Illinois
Additional Information
Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.
Benefits
We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.
