Clinical Auditor

About the role

This role provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge and federal regulations to ensure correct billing practices. The incumbent performs itemized bill reviews to identify billing abnormalities, unbundling, questionable billing practices and improper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity. Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role.

Responsibilities

• Review and analyze complex inpatient and outpatient charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type including any additional information perceived as unbundled items and/or inappropriate charges.
• Documents audit results and updates systems accordingly.
• Assist management in the daily operations and processes within the department.
• Identify opportunities for recovery and avoidance.
• Researches opportunities to better control overpayments and presents ideas to management.
• Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research.
• Provide general support to clinical team members, serving as a resource and subject matter expert (SME).
• Monitors turnaround times for multiple applications and provides suggestions for process efficiencies.
• Uses independent decision making skills to review claims after business hours to meet deadlines.
• Apply national coding standards and regulations to claims billed.
• Research and review individual claims, claim trends or detailed itemized bills, operative notes and other documentation as needed.
• Monitor, research, and summarize trends, coding practices, and regulatory changes.
• Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed.
• Communicates clinical, coding and reimbursement findings to co-workers and management in a clear, organized manner.
• Partner with management to drive department goals and objectives.
• Collaborate, coordinate, and communicate across disciplines and departments.
• Ensure compliance with HIPAA regulations and requirements.
• Demonstrate Company's Core Competencies and values held within.

Requirements

• Completion of educational curriculum required of medical license or coding certification held with Bachelor's Degree preferred; and at least 5 years of coding experience.
• Minimum 5 years experience in direct patient care, medical procedure billing, medical insurance auditing, line item review, audits, coding, and/or reimbursement.
• Extensive knowledge of inpatient/outpatient hospital billing including UB-04s, revenue codes, itemization of charges, CPT codes, HCPCS codes, ICD-10 diagnoses and procedure codes.
• Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria and applicable industry standards.
• Knowledge of commonly used medical data resources.
• Auditing and health information management experience in a healthcare setting preferred.
• Experience with facility contract interpretation.
• Experience and proficiency using MS Office Suites: Excel, Outlook and PowerPoint.

Skills

• Excellent communication (written, verbal and listening), interpersonal, organizational, time-management, analytical, problem-solving, trouble-shooting, customer service skills.
• Ability to develop educational materials and job aids pertaining to coding and claims.
• Ability to work evening or weekend hours as needed to meet deadlines.
• Ability to handle multiple tasks in a fast paced environment.
• Ability to meet individual and team goals, deadlines and work standards.
• Ability to apply independent judgment and determine appropriate course of action.
• Ability to read and abstract medical records.
• Knowledge of medical terminology, anatomy, and physiology.
• Ability to interact and