Auditor Clinical Validation Outpatient Specialty Clinical

Responsibilities

• Audits Outpatient and Specialty Claims: Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims.
• Draws on advanced coding expertise and industry knowledge to substantiate conclusions.
• Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues.
• Effectively Utilizes Audit Tools: Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties.
• Enters claim into Cotiviti system accurately and in accordance with standard procedures.
• Maintains production goals, accuracy and quality standards set by the audit for the auditing concept.
• Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
• Identifies New Claim Types: Identifies potential claims outside of the concept where additional recoveries may be available.
• Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.
• Recommends New Concepts And Processes: Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience.
• Evaluates information and draws logical conclusions.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.

Qualifications

• Education (required): Associate or bachelor’s degree in nursing (active /unrestricted license) AND Certifications/Licenses (required). Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT.
• 5 to 7 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
• Working knowledge of HIPAA Privacy and Security Rules, CMS security requirements and clinical medical record coding or auditing.
• A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• Ability and desire to utilize base coding and clinical auditing knowledge to learn and become proficient in a variety of outpatient and specialty review types.
• Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates.
• Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes.
• Excellent verbal and written communication skills.
• Ability to work well in an individual and team environment.