Develops policies and procedures for medical audit program for Scott & White Health Plan (SWHP), insuring that audit procedures are maintained and adhered to and are compliant with state and national regulations.
RESPONSIBLE FOR ASSESSMENTS AND DEVELOPMENT OF AUDIT PROGRAMS MAINTENANCE. PERFORMS QUALITY AUDITS BY EXAMINING BILLING CRITERIA, UTILIZATION REVIEW STANDARDS, AND VALIDATING AUDIT FUNCTIONS.
* Develops a multi-faceted audit plan for DRG validation, inpatient and outpatient hospital billing, skilled nursing facility audits, contract terms validations, APC validations, high cost drug audits, itemized bill reviews and durable medical equipment audits.
* Analyzes current provider contractual arrangements to identify areas of risk and appropriate stratification. Develops a complete reimbursement validation program that addresses possible areas where payment errors or overcharges may be occurring based upon contractual language and reimbursement methodology.
* Monitors audit plans over time for continual improvement of processes
PERFORMS BILLING AND CODING AUDITS TO ENSURE CHARGES ARE SUPPORTED BY APPROPRIATE CLINICAL DOCUMENTATION, REVIEW MEDICAL RECORDS, RESOLVE PATIENT'S INQUIRIES CONCERNING CHARGE ISSUES, ALONG WITH MANY OTHER GENERAL NURSE AUDITOR RESPONSIBILITIES.
* Conducts reviews of medical records, charges and associated documentation, researching and applying knowledge related to billing and coding guidelines searching for billing, coding and unsupported (or clinical) documentation in provider billing. Analyzes documentation to determine the accuracy and completeness of clinical and financial information maintained in support of charge reductions.
* Validates the accuracy of claim billing, and subsequent payments to, healthcare providers via medical audits. Alternatively, identifies billing errors and recovers overpayments for health claim payers to control health claims costs.
ESTABLISHES AND IMPLEMENTS SWHP INTERNAL POLICIES AND PROCEDURES. DEVELOPS CORRECTIVE ACTION PLANS AS REQUIRED.
* Develops a process for reviewing claims and rendering payment in timely manner.
* Develops an appropriate communication tool with the providers regarding reduction in reimbursements.
* Creates an administrative hearing program for disputed audits.
MANAGES WORKFLOWS AND ANALYZES AUDITS TO ENSURE COMPLIANCE WITH ALL REGULATORY BODIES AND SWHP POLICIES AND PROCEDURES.
* Manages audit workflows, interacts at the audit and auditor level to ensure accuracy, timeliness and that results are consistent with state and federal regulations
* Analyzes medical record documentation to insure that coding and abstracted data is compliant with coding guidelines
* Obtains and analyzes audit evidence as a basis for informed, independent, objective opinions. Documents audit conclusions relevant to objectives and significant findings. Evaluates the significance of audit findings and assesses the degree of operational, compliance and financial risk. Recommends improvement in management controls, policies and procedures as necessary.
PROVIDES EDUCATION FOR EXTERNAL PROVIDERS ON CORRECT BILLING PRACTICES AND REVIEWS SPECIFIC AUDIT ISSUES; TRAINS STAFF ON CODING ISSUES AND BILLING AUDITING. ENSURE EDUCATION AND BILLING IS COMPLIANT WITH PAYER REQUIREMENTS.
* Maintains technical proficiency and remains current with the latest developments, advancements and trends in billing and coding compliance by attending educational programs, reading professional journals, actively participating professional organizations and maintaining certification.
* Maintains a positive working relationship with physicians, nurses, medical administrative colleagues to ensure that all work related encounters are collegial.
* May oversee the daily activities of assigned staff.
PERFORMS OTHER POSITION APPROPRIATE DUTIES AS REQUIRED IN A COMPETENT, PROFESSIONAL AND COURTEOUS MANNER.
KNOWLEDGE, SKILLS, AND ABILITIES
* Certified Coder; Certified Medical Audit Specialist (CMAS) preferred
* Three to Five years experience in Utilization Review, Medical Coding, or Health Experience Preferred.
* Requires comprehensive knowledge of medical, administrative, ethical and legal requirements and standards related to healthcare delivery and privacy of protected patient information.
Experience: 3+ Years
License/Certificate: Registered (Professional) Nurs (RN)
Department: Health PIan Ops Claims Operations
Standard Hours Per Week: 40