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Role Description

Perform medical and revenue audits to ensure revenue integrity as related to adherence to federal and state regulations: policies of external payers, coding rules and guidelines. Exercise independent decisions using analytical and problem-solving skills. Provides critical analytical and negotiation support with respect to third-party payer reimbursement contracts.

Duties and Responsibilities of this Level

• Responsible for responding to all HB and PB government and commercial audits/additional documentation requests in a timely manner. Responsible for all follow up of any denials to include Discussion requests, 1st level appeals, 2nd level appeals, Administrative Law Judge and Medicare Administrative Contractor appeals as necessary (30%)
• Responsible for conducting quality control and prospective audits to ensure data/documentation integrity; compiling information and/or preparing reports and analyses communicating results with appropriate recommendations, including regulatory requirements, and overseeing the corrective actions for audits within the operational units. (10%)
• Serve as Subject Matter Expert in leadership on issues related to revenue integrity (external medical audit request). (10%)
• Perform pre-bill analysis of Medicare accounts with high likelihood of future audit and/or clinical issues with adherence to guidelines prior to release. Work with clinics and stakeholders to ensure accurate data and guidelines met. (20%)
• Follow up with appropriate health team members to ensure accurate and complete documentation in the medical record. Work collaboratively with the appropriate operational leaders to develop provider and service line education strategies to promote complete and accurate clinical documentation, using root cause analysis to correct negative trends and behaviors, and be able to impart this knowledge to providers and other health team members. (10%)
• Review charges and payments for accuracy from contracted payers and management of the appeals process with each assigned payer in both the hospital and clinic settings. Provides critical analysis and negotiation on behalf of DUHS with respect to third-party payer reimbursement contracts. (10%)
• Perform other related duties incidental to the work described herein. (10%)

Qualifications

• Bachelor's degree in business administration, accounting, management, healthcare administration, nursing or another related degree.
• 3 years of experience related to auditing and/or coding is required. Clinical experience is preferred.
• Coding certification (e.g. CPC, CCS, RHIA, RHIT) or applicable experience is preferred. Nursing strongly preferred.
• In-depth knowledge of Medicare/Medicaid regulations, including billing, coding and documentation requirements.
• Knowledge of reimbursement methodologies – DRG, Case Rate, Groupers, APC.
• Revenue Cycle and/or denial management experience.
• Strong oral and written communication skills.
• Intermediate knowledge and skill with Microsoft Office products—Excel, PowerPoint, Outlook, and OneNote.
• Research-oriented with ability to critically analyze and reason large amounts of data.

Company Description