General Summary:
The auditor is responsible for analyzing and auditing inpatient and professional claims to identify inappropriate coding and billing practices/patterns, including those related to unbundling, upcoding, investigational services, and non-medically necessary services. The auditor is responsible for researching, interpreting, and applying HAP specific policies and contract provisions. The auditor will negotiate with client and hospital representatives to resolve identified issues on a case-by-case basis. The auditor will request medical records from providers and conduct medical record audits.
Principal Duties and Responsibilities:
Review of Claims PaymentsAssist in formulating plans to develop an ongoing process to identify opportunities for recovering erroneous or fraudulent claims.Analyze various billing issues and make recommendations to the appropriate departments for improvements.Utilize internal software to analyze provider payment patterns and identify cost saving opportunities.Review paid claims for various contract changes and conclude on accuracy of payments.Work with providers to collect monies due to HAP in cases of overpayments.Identify, evaluate and assist in the implementation of other opportunities for cost savings (not necessarily related to claims payments) or revenue enhancement through operational audits or other means.Examines random claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.Performs medical record audits including audit of claims, rate tables, fee screens, and other payment mechanisms to ensure accurate payment of financial obligations in accordance with policies and procedures and contractual arrangements and benefit design.Keep current with industry fraud, waste, and abuse trends and activity both local and national level.Perform root cause analysis and submit recommendations for appropriate change management when audit findings do not reflect accurate payments (i.e., over or underpayment findings).Assist in the preparation of the annual audit work plan.Investigate fraud, waste, and abuse allegations through interviews, data analysis, and medical record audits.Assist in keeping department policies and procedures current along with being a subject matter expert to other departments regarding coding and documentation guidelines and requirements.Perform additional duties as required.
Education/Experience Required:
Bachelors’ Degree in Health Administration or related field. Relevant or related experience may be considered in lieu of academic requirements. Related experience is defined as six (6) years’ experience in claim audits or medical record audits.
Minimum three (3) years of claim audit, medical record audit or professional audit experience.
Minimum five (5) years’ experience working in the health care industry.
Knowledge of CPT, HCPCS, and ICD-10 coding systems and working knowledge of healthcare compliance are required.
Ability to work with and interpret claims data and medical record documents and communicate effectively with providers, and members.
Ability to work with automated financial systems.
Must be able to demonstrate ability to design complex spread sheet based and database applications.
Knowledge of medical claims data and managed care membership data.
Knowledge of industry claims, healthcare and medical terminology.
Proficient with health care claims data and payment methodologies.
Knowledge of CPT, ICD-10, HCPCS, APC and DRG’s.
Knowledge of Medicare and Medicaid reimbursement methodologies.
Knowledge of anatomy, physiology, disease-process, medical terminology, pharmacology, and coding systems.
Strong initiative, well organized, and possess strong problem-solving communications skills and be able to work independently.
Certifications/Licensures Preferred:
· Coding Credentials: (e.g., CPC, CCS-P, CPC-H, CCS, RHIA, RHIT)
Additional Information Organization: HAP (Health Alliance Plan) Department: Payment Integrity Shift: Day Job Union Code: Not Applicable