Senior Auditor Appeals - OPSP

Responsibilities

• Utilizes all available tools and resources to evaluate each appeal reviewed.
• Applies the policies and guidelines appropriate to the claim/appeal to deliver the most accurate decision.
• Constructs factual, reference-supported responses to the provider describing reasons for the determination.
• Constructs grammatically correct, claim-specific, and professionally written responses to the providers.
• Ensures that service level agreements are met for any work assigned.
• Maintains a minimum productivity standard as outlined for the role.
• May flex into the role of the QA auditor or the initial auditor as business needs require.
• Provides educational feedback to the audit and QA team based upon appeal reviews.

Qualifications

• Education: Associates or Bachelor's degree in Nursing (active/unrestricted license), Associate or Bachelor's degree in Health Information Management (RHIA or RHIT), or equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing.
• Coding Certification: RHIA or RHIT, Inpatient Coding Credential - CCS or CIC preferred, or CCDS or CPC with the requirement to obtain an inpatient coding certification within 1 year of hire.
• Experience: 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
• Medical Record Auditing: 3-5 years of medical record auditing or similar experience.
• Review Types: Ability to utilize and analyze clinical auditing knowledge and skills to learn and become proficient in a variety of review types such as DRG, SNF, Home Health, DME, Hospice, Readmissions, SS, and therapy reviews.
• Compliance: Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
• Skills: Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes, Requires working knowledge of and applicable industry-based standards.
• Software: Proficiency in Word, Access, Excel, and other applications.
• Communication: Excellent written and verbal communication skills.
• Environment: Ability to work well in an individual and team environment.

Starting Salary

Starting salary for this position is $101,000 (48.56/hour).