Compliance Auditor – OP-Ambulatory Services

Job description

This entry-level position is responsible for auditing outpatient and professional services claims to federally funded healthcare payors across the Baptist Physician Enterprise (BPE) organization. The position analyzes coded records for accuracy and compliance with federal, state and third-party insurer rules and regulations and applicable coding guidelines. The position provides guidance to Operations and staff on error trends and how to prevent/reduce errors to strengthen compliance with the False Claims Act, the Federal Overpayment Rule, CMS and Medicaid billing and coding requirements. This role requires a keen eye for detail, excellent communications and critical thinking skills, and a commitment to maintaining the highest ethical standards.
• Performs routine and targeted audits of patient services and corresponding claims submitted to government payors.
• Audits outpatient (OP)/professional service records/claims to ensure adherence and accuracy rate per corporate policy, and recommends any necessary corrective action, education, and training.
• Audits the assignment of International Classification of Diseases 10-CM (ICD-10) diagnostic and ICD-10-PCS procedural codes, Current Procedural Terminology (CPT) codes with modifiers, and other applicable codes in an accurate and productive manner on sampled outpatient/ambulatory cases.
• Reviews, analyzes and abstracts physician/other documentation for diagnoses, procedures, ancillary testing, medications, laboratory and other services provided.
• Utilizes Healthicity or other compliance and audit systems, develops and maintains comprehensive audit reports and documentation of each audit performed, cases sampled, and audit findings.
• Meets with audited providers/department leadership to present audit findings and recommendations. Educates Operations regarding performance patterns of records audited.
• Provides information to physicians and other health care staff regarding documentation requirements, current coding practices and changes in state and federal regulations and guidelines relative to audits performed.
• Participates in and provides education sessions as needed on specific coding topics at huddle meetings and other forums, as directed.
• Communicates with physicians and other health care staff to obtain the location of documentation or to clarify existing information.
• Maintains responsibility for the identification of claims that require correction or other reimbursement related remedies to cure coding and billing errors identified through audit activities.
• Maintains responsibility for operational excellence; ensures the delivery of quality audit services in accordance with applicable policies, procedures, and professional standards.

Minimum Education
• Bachelor's Degree Health Information Management, Related field Required or
• Four years of related experience in lieu of bachelor’s degree Required

Minimum Work Experience
• 5 years Experience in a healthcare provider environment Required
• 1 year Healthcare coding and billing experience Preferred
• 0-1 year Experience with the following applications and systems: Healthicity, Electronic Health Records (i.e. Altera Sunrise, Epic), Hyland MRM, Clintegrity, FinThrive, and MS Office Suite and Excel in particular Preferred