The Clinical Billing Auditor will be responsible for conducting objective reviews of patient accounts when requested by payers, audit firms, associates, or patients. These reviews require analysis of coding, billed charges, and a review of the medical record documentation to support the billed services. The Auditor will ensure that audits are completed within deadlines to prevent any undue financial impact to the care sites and system.
In the event of an on-site claim audit, the Auditor will be responsible for the compilation of all necessary records and scheduling of any meetings with associates or external audit personnel. The Auditor will be the primary contact for follow up and oversight of any remediation required by audit findings.
The Auditor will also serve as liaison to payers, business partners, and associates in coordinating and assisting with denial and appeal activities. In this role, the Auditor will conduct regular meetings with care sites to review appeal opportunities and findings. The Auditor will produce regular reports of appeal activity and outcomes for each care site and the system as needed.
In addition, the Auditor will collaborate with Clinical Documentation Improvement (CDI) teams and/or Care Management to provide education based on outcomes of audits and appeals. This will involve data analysis and reporting, and an ability to communicate clinical documentation requirements to a variety of stakeholders.
The Auditor will complete other projects and initiatives of the Revenue Integrity Team. This may include conducting meetings, conducting and analyzing regulatory research, performing audits and data analysis, and preparing documents or reports related to Revenue Integrity Team activities.
- 2 or 4 year nursing degree with current CO license to practice nursing with 3-5 years related work experience. Would consider LPN with 5-7 years of substantial related work experience.
- Knowledge and understanding of charge master document, case management processes, managed care system, coding and reimbursement preferred.
- Experience in compliance and auditing in a healthcare setting preferred.
- Knowledge of RAC and other state/federal billing audit programs preferred.
- Intermediate knowledge in 2010 Microsoft Office Products required: Word, Excel, Access and Power Point.
- Analytical and decision-making skills required: Define problems, collect data, establish facts, draw conclusions and determine action plan.
- Strong organizational skills required: Attention to detail, timely follow through, and meeting coordination.
- Strong communication skills required: Ability to communicate effectively and diplomatically with internal and external stakeholders.
- Previous project management and/or software implementation experience preferred.
- Knowledge of or experience with change management principles and process/performance improvement methods preferred.
- Willingness to be flexible with schedule and ability to travel up to 20%.
- Ability to multi-task and possess effective time management skills
- Must be self-directed, adaptable, and proactive in performing daily tasks.
At Exempla we believe our patients deserve nothing but our very best. If excellence inspires you and belonging motivates you, we welcome you to join us. We are Exempla Healthcare!
Exempla Healthcare - 2 years ago