Pro Fee Auditor, Educator

Role Overview

• Directly supports the responsibilities of the Coding and documentation quality assurance (CDQA) team: implementation of and compliance to enterprise-wide and department coding policies and procedures for PHS.
• Compliance to all external regulatory agency coding rules and regulations.
• Demonstrates high-level of proficiency in performing and/or managing on-site internal audits or reviews to assess compliance/quality monitoring performed by PHS/PMG departments.
• Serves as a resource on documentation, coding, billing, and coding compliance questions.
• Works on special coding compliance related projects, develops and presents educational programs, disseminates information to PHS/PMG departments and develops educational tools used to maintain compliance with regulations.
• Provides support via auditing and training the enterprise-wide corrective action plans for coding, audit, physician and clinician personnel identified as low performers.
• Perform medical record and billing reviews of denied and appealed claims and takes appropriate action to ensure accurate payment of claims.
• Coordinate review and tracking of appealed claims including the communication process with affected payers.
• Research and interpret all regulatory agency regulations.
• Liaison to the Manager, Information Services, Finance/Patient Financial Services, all hospitals, all PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance and all ancillary departments in addressing functional coding, auditing, compliance and training issues and problems.
• Interact with all levels of management responsible for maintaining accurate, complete and timely documentation in either electronic or hard copy form.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area.
• Researches coding, billing and charging compliance issues, recommends and implements corrective action plans that assure compliance with regulatory agencies where appropriate.
• Identifies risks, develops and follows up on action plans, identifies lost revenue opportunities and any overpayments due to errors in coding and/or documentation, and provides compliance education.
• Assists in the creation of the CDQA Annual Audit Work-plan by utilizing the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, and internal and external risk assessments.
• Regularly exercise independent judgment in determining the reliability of data reviewed; recommends changes in existing practices to gain or maintain compliant behavior.
• Keeps actively informed on the business climate of the healthcare industry.
• Responds to inquiries and requests daily regarding coding and auditing issues and problems and ad-hoc analysis for all PHS management.

Requirements

• High school diploma/GED required.
• Must possess at least one of the following license/certifications: RHIT, RHIA, CPC, CCS
• A minimum of three (3) years experience in coding and/or auditing required.
• Audit experience preferred.
• Excellent written and verbal communication skills.
• Detail and results oriented.
• Ability to work independently and make independent decisions.
• Medical terminology, ICD-9, CPT-4 and HCPCS knowledge required.
• Must have a proficient knowledge of Medicare, Medicaid, and other third party payer documentation, coding, and billing regulations for service lines(s) assigned.
• Must possess excellent organizational and planning skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously.
• Must possess computer skills, especially with Microsoft Word, PowerPoint, and Excel applications.
• Must be able to use the internet and other resource applications for research purposes and to provide documentation that supports regulations quoted in audits.
• Must possess strong written and verbal communication skills in order to communicate in clear, concise terms to management at all levels.
• Must possess a personal presence of a highly qualified professional that is characterized by a sense of honesty, integrity, and the ability to inspire and motivate others.

Tech Stack

• PHP

Benefits

• medical
• dental
• vision
• short-term and long-term disability
• group term life insurance
• other optional voluntary benefits
• wellness program up to rewards and gift cards for wellness activities