This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to be a registered nurse with a preferred coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting, and services delivered.
JOB 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
- Respond to client logics and record reviews
- 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
- Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept
Meets or Exceeds Standards/Guidelines for Quality
- 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
- Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction
- Evaluates information and draws logical conclusions
- Complete all responsibilities as outlined on annual Performance Plan
- Complete all special projects and other duties as assigned
- Must be able to perform duties with or without reasonable accommodation
RELEVANT EXPERIENCE & EDUCATIONAL REQUIREMENTS:
- Registered Nurses with CPC/COC/CIC/CCS certification
- Experience in US Healthcare, medical coding, medical billing, RCM health plan operations strongly preferred
- Possesses knowledge of healthcare claims payment policy and processing – specifically CMS, Medicaid regulations, ICD-10 CM & other code sets, etc.
- Practical clinical experience working in a hospital/office strongly preferred
- Has general knowledge of medical procedures, conditions, illnesses, and treatment practices
- Possesses excellent written and verbal communication skills
- Ability to think logically and process sequentially with a high level of detailed accuracy and efficiency
- Has excellent personal computer skills in Microsoft Word, Excel, PowerPoint, Outlook, etc.
- Willing to work onsite.
