Regulatory Review Program RN

This is a remote position

The CommonSpirit RRP RN ensures regulatory compliance for Care Coordination activities, collaborating with Revenue Cycle, Compliance, and other stakeholders. This role audits patient records to identify risks, ensuring adherence to System policies, regulatory requirements, accurate medical necessity reviews, and proper claim submission.

This position conducts scheduled, system-wide Care Coordination audits to achieve organizational objectives. Utilizing a systematic approach, the RRP RN evaluates and improves risk management and quality control by completing audits, analyzing findings, and preparing them for leadership review. The role also involves case review and research to support compliant and accurate claim submission, reduce payment delays, and maximize reimbursement. Incumbents apply professional judgment, independent analysis, and critical-thinking skills to clinical guidelines, policies, and regulatory requirements for appropriate medical necessity review, claim billing status, and discharge planning.

Employees are accountable for demonstrating a strong commitment to quality and organizational values: Compassion, Inclusion, Integrity, Excellence, and Collaboration. This is a remote position.

Essential Functions:

• Apply knowledge of Medicare billing rules and regulations.
• Determine ADT status using screening tool guidelines and Intensity of Service/Severity of Illness criteria, completing thorough clinical chart reviews.
• Conduct and complete Care Coordination regulatory and compliance audits.
• Analyze and report audit findings to RRP Leadership.
• Identify potential compliance issues requiring resolution before billing release.
• Collect and analyze data to identify and track trends.
• Facilitate second-level physician reviews for appropriate level of care determination.
• Document in the electronic medical record.
• Communicate/escalate issues to appropriate stakeholders.
• Communicate appropriate level of care and release for billing.
• Assist with new RRP RN orientation and training.
  
  

Required Education and Experience

• Bachelors degree or equivalent combination of education and experience may be considered.
• 5 years of general acute care experience
• Current RN license
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification.
• Care Coordination experience with regulatory compliance and audit experience is preferred.
• At least 2 years of denial management, claims review, clinical documentation integrity or similar experience is preferred.

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.