Claims Integrity Auditor

Work Shift:

Day (United States of America)

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview:

Claims Integrity Auditor

JOB CODE:30250

SUMMARY (BASIC PURPOSE OF THE JOB)

Provides technical and analytical support for patient account billing analysis and evaluation in the performance improvement process. Performs chart review in identifying if variation from quality of billing exists. Monitors internal charges and patient bills for accuracy, compliance, and responsibility.

MINIMUM REQUIREMENTS

Education:Any healthcare technical license including Registered Nurse (RN), ARRT, or Registered Health Information Technician (RHIA/RHIT).

Experience:Three years of technical experience within a healthcare environment. Previous auditing, medical claims analysis, or Health Information Management experience in a healthcare setting preferred.

Other Credentials:

Knowledge and Skills:Demonstrates excellent verbal and written communication skills. Strong data analysis and problem-solving skills. Proficient in basic computer applications such as Word, Excel, and PowerPoint.

Special Training:Must possess thorough knowledge of medical terminology, anatomy, and physiology. Understanding of ICD-9/ICD-10 and CPT coding classifications.

Mental, Behavioral and Emotional Abilities:

Usual Work Day:8 Hours

REPORTING RELATIONSHIPS

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Serves in a quality capacity verifying all charges on a patient account and is well-versed in all areas of the chart in order to determine appropriate charges.
• Understands patient billing requirements and applies this knowledge during chart review in order to verify that all appropriate charges have been added and that all inappropriate charges are removed. Performs compliance audits of records to ensure documentation is present to support all charges posted to the patient account.
• Collaborates directly with nursing units, ancillary departments, directors, and managers related to charging to ensure compliance with Federal and State regulations and continuous quality improvement.
• Reviews charts for documentation-related quality concerns including unsupported charges and services and misuse of departmental billing processes.
• Reports discrepancies to appropriate directors and managers and ensures that corrective action is taken in a timely manner.
• Performs chart review to identify if variation from quality billing exists and if so, determines the need for peer review. Identifies concerns and make recommendations for review to improve the process. Communicates findings as appropriate to staff/departments involved.
• Coordinates and performs preliminary review of charts selected by third party payers to ensure documentation is appropriate. Reviews data for external and internal requirements. Resolves issues as required.
• Reviews audit results from third payers and supplies additional information if in disagreement with findings. Keeps department apprised of status and relays up-to-date statuses as required.
• Manages loggings, filing, and storage of audited Medicare and Managed Medicare records. Ensures integrity of data and corrects errors as needed.
• Performs other duties as assigned and adapts to changing departmental demands.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include:

Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities

Continuous physical demands include: Sitting , Keyboard use/repetitive motion , Talk or Hear

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: N/A

Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

"Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."