A bit about this role
The Clinical Readmission Manager is responsible for conducting prepayment and post-payment clinical reviews of inpatient hospital admissions and subsequent admissions to the same or a related hospital within 30 days of the prior discharge date.
The auditor reviews claims and medical records for both admissions to determine whether the readmission is clinically related to the prior admission and/or potentially preventable under applicable organizational, regulatory, and Payment Integrity guidelines.
This role requires strong inpatient clinical knowledge, sound clinical judgment, and experience reviewing hospital records and readmission cases. The Clinical Readmission Auditor is responsible for producing accurate, timely, objective, and defensible clinical determinations and supporting documentation. The auditor also prepares initial findings, dispute responses, and appeal documentation related to readmission reviews.
Your Responsibilities and Impact will include
- Conduct Clinical Reviews: Perform prepayment and post-payment clinical reviews of inpatient admissions and related readmissions occurring within 30 days of a prior discharge. Review applicable claims and medical records to assess the clinical relationship and potential consolidation of the readmission.
- Apply Review Guidelines: Apply established organizational policies, regulatory requirements, readmission criteria, and applicable exclusions consistently when evaluating cases.
- Document Determinations: Prepare clear, objective, timely, and defensible clinical rationales and supporting documentation for review findings.
- Support Disputes and Appeals: Prepare initial findings, dispute responses, and appeal letters, and review additional documentation submitted during the dispute or appeal process.
- Collaborate on Complex Reviews: Partner with Payment Integrity, appeals, quality, utilization management, and other internal teams to address complex, escalated, or disputed cases.
- Promote Quality and Consistency: Participate in calibration sessions, peer reviews, quality reviews, and case discussions to support accurate and consistent review outcomes.
- Maintain Compliance and Documentation: Maintain accurate records in applicable clinical review and audit systems while protecting confidential patient, member, and provider information.
- Support Continuous Improvement: Identify trends, documentation concerns, and opportunities to improve readmission review processes and outcomes.
Required skills and experience
- Licensure: Registered Nurse degree with a current, active, and unrestricted RN license in at least one U.S. state. A multistate license is not required.
- Relevant Experience: Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or a related healthcare environment, including demonstrated experience reviewing inpatient hospital readmissions.
- Clinical Expertise: Strong knowledge of inpatient clinical care, disease processes, complications of care, discharge planning, and transitions of care. Ability to evaluate whether admissions are clinically related and/or potentially preventable.
- Medical Record Review: Experience reviewing medical records and synthesizing clinical information from multiple sources, including the ability to identify clinical, documentation, discharge planning, follow-up, and care coordination factors that may contribute to a readmission.
- Audit and Determination Skills: Experience applying established clinical criteria, policies, regulatory guidance, and review methodologies. Ability to exercise sound clinical judgment and prepare clear, concise, objective, and defensible clinical rationales, findings, dispute responses, and appeal documentation.
- Analytical and Organizational Skills: Strong critical-thinking, analytical, problem-solving, and attention-to-detail skills, with the ability to manage multiple priorities and meet deadlines in a remote work environment.
- Communication and Collaboration: Strong written and verbal communication skills, with the ability to work independently and collaborate effectively with clinical, Payment Integrity, quality, appeals, utilization management, and operational teams.
- Technology Skills: Experience using electronic medical records, claims information, clinical review systems, or audit workflow platforms.
Desired skills and experience
- Bachelor of Science in Nursing or bachelor's degree in a related healthcare field.
- Experience conducting clinical readmission reviews for a health plan, hospital, Payment Integrity organization, or external audit vendor.
- Experience with Medicare, Medicaid, commercial payer, QIO, State Operations Manual, or payer-specific readmission criteria.
- Experience reviewing potentially preventable readmissions, hospital-acquired complications, discharge planning concerns, or care transition issues.
- Experience handling disputes, appeals, reconsiderations, or escalated clinical reviews.
- Experience participating in clinical calibration, peer review, quality assurance, or reviewer education.
- Experience identifying readmission trends, documentation concerns, and opportunities for process improvement.
- Familiarity with inpatient coding, DRG methodology, clinical validation, or hospital bill audits.
- Experience working in a remote clinical review or audit environment.
- Familiarity with automation, artificial intelligence, or other technology used to support clinical audit and review workflows.
Salary range: $73,000 - 125,000 annually