Perform audits and investigations with a primary focus on billing and coding compliance by reviewing medical records and claims to determine compliance with reporting and billing regulations as evidenced in medical record documentation and appropriateness of billing and coding procedures.
Requires expertise in knowledge of ICD-10-CM, CPT, Level II HCPCS, claims review, payer regulations and payer requirements. Work involves actively directing and conducting compliance audits, investigations, corrective action plans, regulatory research, workforce education, and providing consultative services to the client’s senior leadership, providers and staff; providing key contributions to the development of the Corporate Compliance annual audit work plan, awareness and mitigation of revenue cycle risks; and providing training and coaching to client providers, clinicians, coders, billers and ancillary staff. Maintains and promotes all organizational and professional ethical standards. Works autonomously under general supervision of the Project Manager.
Independently completes assignments, manages audits and projects, performs regulatory research, investigations, participates and collaborates in the claims review process, providing documentation and compliance educational sessions to senior leadership, clinical staff, providers, revenue cycle leadership and staff, auditing and monitoring the quality and data integrity of of the client’s coding, documentation and billing practices.
Communicates and interacts with a wide cross-section of executive leaders, directors, managers, providers and front-line workforce to fulfill job requirements.
Ability to define audits, identify potential risk areas, create transparency with operations, understand operational workflows, document findings, draft reports, develop appropriate action plans, and communicate results to leadership (within minimal oversight).
Liaise with Operations to ensure audit findings are remediated and action plans are sustained and to identify emerging risks.
Apply judgment to ensure compliance with coding, documentation, and billing laws, regulations and guidelines to safeguard, protect and disclose against fraud, waste and abuse while receiving appropriate reimbursement for the care provided.
Conducts audits, interviews, reviews documents, and summarizes and documents key issues and ability to communicate results effectively to workforce and senior leadership.
Skill in conducting audits and reviews by using strong critical thinking skills, operational workflow knowledge, ability to research, as well complete and thorough documentation of all findings.
Evaluate practice patterns, data-mining, analyze and present oral and written conclusions to leadership and departments in applying and improving compliance and internal controls.
Provide on-going audits, training and education.
Excellent ability to sustain focus and attention to detail.
Strong ability to problem solves and assess potential risks identified, prioritize concerns, and provide educational needs to various skill levels, such as physician, ancillary, nursing, coding and billing workforce.
Considerable knowledge of and skill in providing education on federal and state rules and regulations, coding and billing principles and practices (i.e. AHIMA, AMA, CPC, Federal Register, CMS, OIG and commercial payer requirements).
Act as a resource for documentation, coding, claim review process, and billing questions
Maintain up to date with local, state, federal laws, regulations and guidelines, as well as monitoring payer bulletins, periodicals and websites to maintain revenue cycle knowledge.
Advanced written and oral communication and presentation skills a must.
Participates in compliance meetings when requested by clients.
Expertise in ICD-10-CM, CPT, Level II HCPCS coding methodologies
5 years of coding and/or auditing experience
Extensive knowledge of current OIG Work Plans, CMS OPPS, CMS Program Integrity Manual, CMS Code Editor, CMS National Coverage Determinations, Third Party Payer Local Coverage Determinations, and other regulatory references
Experience navigating an Electronic Medical Record System
Experience with coding encoder
Experience with Microsoft Office tools
Associate or Bachelor degree
2 Years Compliance Auditing Experience
Data analytics software experience
AAPC Certified Professional Medical Auditor (CPMA) credential
This is not a remote position