Clinical Nurse Auditor - HB Patient Financial Services - FT Days

Who We Are

UCI Health is the clinical enterprise of the University of California, Irvine, and the only academic health system based in Orange County. UCI Health is comprised of its main campus, UCI Medical Center , a 459-bed, acute care hospital in in Orange, Calif., four hospitals and affiliated physicians of the UCI Health Community Network in Orange and Los Angeles counties and ambulatory care centers across the region. Listed among America's Best Hospitals by U.S. News & World Report for 23 consecutive years, UCI Medical Center provides tertiary and quaternary care and is home to Orange County's only National Cancer Institute-designated comprehensive cancer center , high-risk perinatal / neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center , gold level 1 geriatric emergency department and regional burn center . UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County.

To learn more about UCI Health, visit www.ucihealth.org.

Your Role on the Team

Position Summary :

The incumbent is responsible to perform review of denied claims, conducting medical records reviews with use of standardized medical review software, determining claim appealability and initiates formal written or verbal appeals with various health plans. Must have knowledge of medical terminology, various health plan products (Medicare, Medi-Cal, HMO, PPO, Managed Care, etc.) private insurance and CMS guidelines. Previous experience substantiating appeals for Trauma, Acute and Psychiatric services. Also responsible for conducting external charge defense audits requested by insurance companies in collaborating with various audit firms for the conclusion of audits. Performs additional related duties, as assigned.

What It Takes to be Successful

Required Qualifications :

• Three years' experience working in clinical denial review and / or clinical appeal processing
• Three years of related clinical experience in an acute care setting
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
• Must possess a current California RN license
• Must demonstrate customer service skills appropriate to the job
• Knowledge of Interqual
• Five years of internal and / or external audit experience
• Familiarity of audit software packages
• Excellent written and verbal communication skills in English
• Competent knowledge and experience with Microsoft Office computer applications, i.e. Word, Excel
• Ability to maintain a work pace appropriate to the workload
• Ability to establish and maintain effective working relationships across the Health System

Preferred Qualifications :

Total Compensation

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits .

Conditions of Employment :

The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment :

Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

Details of each policy may be reviewed by visiting the following page : https : / / hr.uci.edu / new-hire / conditions-of-employment.php

Closing Statement :

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy .

We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.

UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at eec@uci.edu or at (949) 824-0500, Monday - Friday from 8 : 30 a.m. - 5 : 00 p.m.

Consideration for Work Authorization Sponsorship

Must be able to provide proof of work authorization