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 while serving 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.
• Interacts with all levels of management
• Responsible for maintaining accurate, complete and timely documentation in either electronic or hard copy form
• Must be able to adapt to frequently changing work priorities and schedules
• 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, as well as internal and external risk assessments
• Regularly exercises 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, including the ability to articulate complex regulatory information in laymans terms.
• 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
• Employee Wellness rewards program