Medical Internal Auditor
Vidant Health - Greenville, NC

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Position Summary

Responsible for conducting audits involving the entire revenue cycle. Following established protocols, perform concurrent and/or retrospective audits reviewing medical record documentation against billing to assess compliance with all laws, rules, policies and procedures, and regulations. Identify charge error rates, procedural weaknesses, system weaknesses, and coding appropriateness. Performs operational audits to assure compliance with regulatory and departmental policies and procedures, coding and billing accuracy reviews, provides coding education to physicians and health system staff, and conducts compliance monitoring for the health system. Coordination of Recovery Auditor Contractor (RAC) program activities for health system. Knowledge of regulatory guidance impacting health system billing, including Medicare, Medicaid, Tricare, and Health and Humans Services (HHS) Office of the Inspector General (OIG). Position requires travel to entities throughout the health system.

Responsibilities

1. Responsible for performing audits involving the entire revenue cycle. Following established protocols, perform audits reviewing medical record documentation against billing to assess compliance with all laws, rules, policies and procedures, and regulations. Identify charge error rates, procedural weaknesses, system weaknesses and coding appropriateness.

Performs operational audits to assure compliance with regulatory and departmental policies and procedures. Coding accuracy reviews may be conducted for inpatient, outpatient, emergency department; ambulatory surgery visits on a prospective or retrospective basis.

2. Develop detailed audit programs of varying degrees of difficulty, complexity and scope. Determine the scope of work, depth and breadth of audit testing needed. Produce high-quality work that is competently and efficiently performed in accordance with professional and departmental standards. Prepare comprehensive reports, making recommendations to correct identified deficiencies/issues, and promote economy, effectiveness and efficiency.

3. Develop and maintain a database, accumulating information and preparing statistical reports on charge accuracy and medical record documentation for management review. Statistical information is developed monthly, based on audit findings, and includes recommendations for correcting weaknesses/issues identified.

4. Provide guidance and assistance to management on control aspects of current or proposed activities, systems and procedures to ensure adequacy of internal controls, achievement of objectives, data integrity and appropriate security.

May represent the department on technical or procedural matters in the specialty area.

5. Assist with oversight of governmental audit contractor functions, including Recovery Auditor Contractor (RAC) program activities.

6. Assist with coordination of provider (physician and non-physician provider) coding compliance audits for the health system.

7. Assist with tracking and maintaining status of all governmental audit contractor functions/activity using automated systems (requests, appeals responses, etc).Conduct periodic follow-up on Management action plans to assure implementation of processes to correct errors/weaknesses.

8. Maintain open and effective communication with entity governmental audit contractor coordinators/contacts, Health Information Management/staff, Financial Services and external entities involved in governmental audit contractor processes.

9. Communicate appropriately and effectively in verbal and written form.

10. Develop and maintain professional skills and knowledge through attendance at relevant conferences, seminars and other educational programs; participation in professional organizations; and review of current literature.

11. Assess coding and billing staff knowledge of reimbursement and coding guidelines.

12. Interview personnel involvement in management, operations, coding, claims development and submission, and other related compliance activities to identify potential compliance issues.

13. Maintain audit activity and productivity in departmental database.

14. Use resources effectively and efficiently to achieve departmental goals and objectives.

15. Monitor Medicare, Medicaid, and Tricare resources and websites to remain abreast of changes in processes / policies, and participate in pertinent webinars/seminars. Share new and updated information with entity contacts and Compliance Officers. Monitor Medicare, Medicaid, and Tricare resources and websites to remain abreast of changes in processes / policies, and participate in pertinent webinars/seminars. Share new and updated information with entity contacts and Compliance Officers.

16. Perform other duties as assigned.

Responsible for performing audits involving the entire revenue cycle. Following established protocols, perform audits reviewing medical record documentation against billing to assess compliance with all laws, rules, policies and procedures, and regulations. Identify charge error rates, procedural weaknesses, system weaknesses and coding appropriateness.

Performs operational audits to assure compliance with regulatory and departmental policies and procedures. Coding accuracy reviews may be conducted for inpatient, outpatient, emergency department; ambulatory surgery visits on a prospective or retrospective basis.

Develop detailed audit programs of varying degrees of difficulty, complexity and scope. Determine the scope of work, depth and breadth of audit testing needed. Produce high-quality work that is competently and efficiently performed in accordance with professional and departmental standards.

Prepare comprehensive reports, making recommendations to correct identified deficiencies/issues, and promote economy, effectiveness and efficiency.

Develop and maintain a database, accumulating information and preparing statistical reports on charge accuracy and me dical record documentation for management review.

Statistical information is developed monthly, based on audit findings, and includes recommendations for correcting weaknesses/issues identified.

Provide guidance and assistance to management on control aspects of current or proposed activities, systems and procedures to ensure adequacy of internal controls, achievement of objectives, data integrity and appropriate security.

May represent the department on technical or procedural matters in the specialty area.

Assist with oversight of governmental audit contractor functions, including Recovery Auditor Contractor (RAC) program activities.

Assist with coordination of provider (physician and non-physician provider) coding compliance audits for the health system.

Assist with tracking and maintaining status of all governmental audit contractor functions/activity using automated systems (requests, appeals responses, etc).

Conduct periodic follow-up on Management action plans to assure implementation of processes to correct errors/weaknesses.

Maintain open and effective communication with entity governmental audit contractor coordinators/contacts, Health Information Management/staff, Financial Services and external entities involved in governmental audit contractor processes. Communicate appropriately and effectively in verbal and written form.

Develop and maintain professional skills and knowledge through attendance at relevant conferences, seminars and other educational programs; participation in professional organizations; and review of current literature.

Assess coding and billing staff knowledge of reimbursement and coding guidelines.

Interview personnel involvement in management, operations, coding, claims development and submission, and other related compliance activities to identify potential compliance issues.

Maintain audit activity and productivity in departmental database. Use resources effectively and efficiently to achieve departmental goals and objectives.

Monitor Medicare, Medicaid, and Tricare resources and websites to remain abreast of changes in processes / policies, and participate in pertinent webinars/seminars. Share new and updated information with entity contacts and Compliance Officers.

Monitor Medicare, Medicaid, and Tricare resources and websites to remain abreast of changes in processes / policies, and participate in pertinent webinars/seminars. Share new and updated information with entity contacts and Compliance Officers.

Minimum Position Requirements

REQUIRED:

Licensed RN or Bachelors Degree in nursing, health information management, or health related field.

Three years recent experience in clinical operations, medical record auditing, coding, billing, or reimbursement.

An Associate Degree in Nursing or Health Information Management with two additional years of experience in clinical auditing may be substituted for the four-year educational requirement.

Extensive knowledge of medical diagnosis, treatment protocol, and current Federal and State healthcare rules and regulations sufficient to billing compliance.

Comprehensive knowledge of operational and clinical medical record review/audit concepts.

Extensive knowledge of CPT and ICD codes and third party payer coding and billing regulations.

Proficiency with word processing and spreadsheet programs on a personal computer.

Excellent communication skills, both written and verbal.

PREFERRED:

At least two years recent experience auditing medical record documentation against patient billing records. Professional certification (i.e., CCS, CHC, RHIT, RHIA). Proficiency with database or other automated systems creation, utilization, and/or management.

Other Information 1 full - time vacancy.

General Statement It is the goal of Vidant Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

Vidant Health is an Equal Opportunity Employer. EOE/AA Applications for Vidant Health and its subsidiary corporate entities are accepted and employees are chosen for employment without regard to race, color, gender, religion, age, national origin, marital status, citizenship, veteran status, or disability.

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