Allegheny Health Network Careers

Date Posted: 12/02/2016
Job Title: Compliance Auditor B
Location: Corporate Office
Department: Compliance

Job Summary: Plans and conducts institutional medical record and billing audits for documentation, billing, and compliance with state and federal requirements (audits may include: outpatient clinics, outpatient procedures, ancillary services. Presents audit findings to hospital/physician leadership, creates appropriate audit spreadsheets, provides educational presentations to hospital departments/physicians as applicable to correct audit concerns. Completes special coding billing and documentation audits.

Status: Full-Time
Non-Union

Job Responsibilities:

• Performs internal concurrent, prospective, and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding, billing, and documentation is compliant with appropriate guidelines and federal and state regulations.
• Develops audit detail summary spreadsheets and reports to address any coding, documentation, or financial discrepancies.
• Conducts presentations of final audit findings to department staff, physicians, and appropriate individuals.
• Works with auditees on corrective action plans and educates management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, and coding requirements.
• Responsible for defending payor claims denials for medical necessity, coding, billing, and documentation through coordination of and participation (when appropriate) in the appeal process - RACs, ZPICs, MICs and OIG audits in particular and other payors as assigned.
• Conducts investigations and performs special projects as assigned.
• May provide guidance to hospital entities and performs reviews as needed in response to external medical necessity audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc.

Education: Bachelor's Degree required or equivalent education and experience.

Licensure/Certification/Registration: Current Drivers License (has a car and can  travel throughout Western PA) is required.

For hospital or professional fee auditor: National certification in procedural coding, certified professional coder (CPC), RHIT, or RHIA required.

Complexity of Work: Communicates effectively both orally and in writing; completes duties and assignments independently while working effectively under pressure and deadline situations; identifies problems and effectively problem solves; and, conducts research on current and/or pending regulations. Works on several projects concurrently. Regularly informs the Director of work progress relating to assigned audits and seeks advice or consultation regarding issues or problem areas. Performs functions under routine supervision. Seeks direction from the Director of Compliance for non-routine activities. Demonstrated knowledge of Medicare, Medicaid, and local third party regulations along with advanced ICD-9, 10 and CPT coding / anatomy / medical terminology and hospital/physician billing processes and medical record audit processes. Advanced computer skills in applications such as Microsoft Work and Excel along with proficient writing skills, preparation of workpapers and reports, and presentation of clear and concise findings (oral and written) are also required.

Required Experience: Minimum of 3-5 years experience in hospital/physician coding and documentation reviews required.