Hospital Billing Integrity Auditor

Job Number: 1785

Workplace Type:

Position Title: Hospital Billing Integrity Auditor

External Description:

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. 

General Duties/Responsibilities:

(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.

Supervisory Responsibilities:

N/A

Minimum Requirements:

Minimum Experience:

Three years (3) of performing hospital based inpatient coding experience is required.

Education/Licensure:

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. 

Other:

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.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Hospital Billing Integrity Auditor

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].