Jobs

Description

Job Summary:

• This position is responsible for being the lead audits of hospital billing and coding practices and desk audits; forms development, profiling and tracking institutional audit trends.
• Designing audit protocols and special projects.
• Performs and finalizes multiple per diem, bill verification, DRG Validation (utilization review audits) and credit balance.
• Additionally provides guidance/instruction to various stakeholders on ICD10- CM, DRG assignment payment and auditing.

Responsibilities:

• Identifies and presents billing discrepancies found during audit and coordinates referral of improper claim payments through the appropriate channels.
• Identifies error trends as they relate to medical record and or billing documentation or misinterpretation of provider contract stipulations.
• Compiles statistics and other audit information to present to accounts, regulatory agencies, internal requesters.
• Reviews and updates audit processes with manager for purposes of keeping up with new innovations in clinical data review and company cost containment initiatives.
• Required to train new staff on department/audit procedures.
• Performs other special assignments as requested by manager.
• Demonstrates knowledge, understanding and conforms to laws, regulations and policies that pertain to the organizational units business.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification.

Education/Experience:

• High School Diploma/GED required.
• Bachelor degree in Health Information Management preferred or relevant experience in lieu of degree.
• Requires a minimum of 3 years experience in a medical records department of an acute care hospital or other health care facility. Experience with DRG validation, ICD-10-CM training and education.

Additional licensing, certifications, registrations:

• Requires RN license with CCS or RHIT/RHIA certification
• Preferred CCS, CCS-P or CCA certifications.

Knowledge:

• Requires knowledge of medical terminology, detailed knowledge of anatomy & physiology, disease pathogenesis and treatment including procedural drug therapies, ancillary and diagnostic services.
• Requires knowledge of principles of utilization management.
• Requires knowledge of hospital structures and payment systems.
• Requires knowledge of centers of Medicare and Medicaid prospective payment system regulations.
• Prefer knowledge of ACCESS Software.