Compliance Auditor

Job ID: J125118
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Dec 6, 2018

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Description

GENERAL OVERVIEW:

Plans and conducts institutional medical record, billing, research, and non-coding compliance audits for documentation, billing, and compliance with state and federal requirements (audits may include: outpatient clinics, outpatient procedures, ancillary services, activities in accordance with Stark requirements, physician professional fees or post-acute care services including homecare, outpatient hospice, infusion, and durable medical equipment). Presents audit findings to hospital/physician leadership, creates appropriate audit spreadsheets, provides educational presentations to hospital departments/physicians/ practice staff as applicable to correct audit concerns. Completes special coding billing and documentation audits.

ESSENTIAL 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. (20%)
  • 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. (20%)
  • 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 and other payors as assigned. (20%)
  • Performs internal concurrent, prospective, and retrospective audits to assure that research services and bills are supported by documentation in the medical record, that research activities coincide with study protocol approved by the IRB, and that all documentation is compliant with federal and state regulations. (20%)
  • 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, IRB, etc. (10%)
  • Post-Acute Care Auditor Only: Supports non-audit related compliance program activities for post-acute care as needed including completion of Medicare 855s and other regulatory or licensure paperwork, and research/interpretation of new/existing regulations. (10%)

QUALIFICATIONS:

Minimum

  • Bachelor's Degree or equivalent education and experience.
  • 3-5 years’ experience with compliance / auditing in hospital/physician coding and documentation; or in post-acute care field dealing with regulatory environment including billing, coding, and documentation reviews; or research and review of research documentation.
  • For hospital or professional fee auditor: National certification in procedural coding, certified professional coder (CPC), RHIT, or RHIA; or willingness to pursue successful certification within 1 year.
  • For post-acute care auditor: National certification in procedural coding, certified professional coder (CPC) preferred or equivalent experience (3 years) working in post-acute care auditing / chart review and willingness to pursue successful certification within 1 year.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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