Hospital Billing Integrity Auditor
Location: Orange, California US
Job Number: 1785
Position Title: Hospital Billing Integrity Auditor
The Hospital Billing Integrity Auditor conducts reviews to determine inpatient facility integrity of billing facility and technical hospital fees, including detection of documentation issues, coding and billing errors and/or medical necessity of services billed. Reviews consist of evaluation of the adequacy and accuracy of documentation in support of services billed, including ICD/CPT/HCPCS, DRG assignment, APC code assignment, medical necessity of services, reimbursement over payments, underpayments, and compliance with other documentation, coding and billing standards.
The Hospital Billing Integrity Auditor will evaluate the adequacy and effectiveness of internal and operational controls designed to ensure that processes and practices lead to appropriate execution of contractual agreements, regulatory requirements and guidelines related to facility and technical fee documentation, coding and billing, including federal and state regulations and guidelines, CMS and other third party payor billing rules, and OIG compliance standards.
The Hospital Billing Integrity Auditor serve as institutional subject matter experts and authoritative resources on interpretation and application of documentation and coding rules and regulations, medical necessity of services delivered, and conduct risk assessments of potential and detected deficiencies in inpatient billing practices.
(May include but are not limited to)
·Contributes to the achievement of Claims and Medical Management Department goals and objectives and adheres to departmental policies, procedures and standards; complies with governmental and accreditation regulations.
·Effectively maintains collaborative working relationships with Claims and Medical Management staff.
·Conducts prospective facility and technical fee reviews, specialized and focused reviews when required, and other audits as directed
·Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation; evaluates appropriateness of ICD, HCPCS and CPT codes, evaluates the appropriateness of APC, DRG and admission assignments; evaluates appropriateness of modifier usage; makes determinations of overpayments and underpayments and performs other related analysis and evaluations.
·Prepares written reports of findings and recommendations and presents to Claims and Medical Management Leadership.
·Conducts risk assessments to define review priorities by evaluating previous trends, management priorities, ICD, APC and DRG utilization patterns, national normative data, CMS initiatives, OIG work plans and advisories, and healthcare industry best practices.
·Researches, abstracts and communicates federal, state and other payor documentations, billing and coding rules and regulations; stays current with Medicare and other third-party rules and regulations, DRG, ICD, APC and CPT coding updates, Coding Clinic Guidelines; serves as institutional subject matter expert and authoritative resource in these areas.
·Authors newsletter articles, FAQs, email alerts and other communication and educational materials for provider community; responds to informational inquiries from physicians, providers, claims examiners, management and staff regarding documentation, coding, billing and other related hospital billing matters.
·Assists in identifying areas of enterprise claim risk and aids in resolution as needed.
·Maintains privacy of patient information and confidentiality of compliance information.
·Maintain high level of professionalism.
Three years (3) of performing hospital based inpatient coding experience is required.
An Associate of Science or Bachelor of Science degree in Health Information from an approved AHIMA program is preferred.
Current American Health Information Management Association (AHIMA) certification as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) is required.
Active AHIMA or AAPC membership
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Hospital Billing Integrity Auditor
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