Compliance Auditor Job
Full Job Title: Compliance Auditor II - Full Time
Job Number: 471141
Location: Lakeland, FL
Education: High School diploma or equivalent.
Experience: Minimum 5 years medical coding/healthcare reimbursement experience.
Other Requirements: Certification by American Academy of Professional Coders (CPC) for a minimum of 5 years or equivalent organization and CRC (Certified Risk Coder) certification. CRC (Certified Risk Coder) certification must be obtain within six (6) months of employment. Must have advanced knowledge in medical terminology and anatomy. Must have advanced knowledge of insurance reimbursement, principles and practice. Conduct prospective & retrospective reviews for both inpatient and outpatient physician/provider services. Experience with healthcare claims management systems. Ability to work independently and to exercise appropriate judgment, in setting priorities. Must have knowledge of PC and Microsoft Office. Good analytical, written, verbal communication skills.
Preferred Education and Experience
Clinical experience as RN or LPN with medical coding experience and certification.
- Conducts chart reviews of medical records for outpatient/inpatient providers. Reports on documentation to support CPT, ICD10 codes and RAF scores. Provides timely provider communication by memo and telephone. Facilitates review process by obtaining encounter forms.
- Identifies deficiencies and educational needs ofprovider. Reports clear and detailed recommendations to improve documentation of level of service billed, specificity of ICD10 and RAF Determines the level of in-service education needed for providers. Communicates credible and concise findings in provider reports. Presents in a professional, organized and positive manner.
- Demonstrates a contribution to the department’s operation and goals/targets for the year. Maintains monthly log of activity, Completes 10 charts/quarter for assigned providers. Conducts reviews within the department production rate determined on an annual basis. Prioritizes workload maintains control over interruptions.
- Demonstrates ability to use auditing software program, IDX system, LCD, EHR and local hospital resources to conduct reviews and summary of findings. Ability to use the TES program in IDX for retrospective or concurrent reviews. Pursues medical records needed from outside resources (i.e. SNF, other hospitals).
- Identifies departmental process discrepancies duringreview process. Reports any operational areas of risks identified to assistant director. Recommends improvements to encounter forms. Reports treatment inconsistencies for review.
- Possesses a comprehensive understanding of carrierspecific, State or Federal governmental, CMS, or CPT billing and reimbursement guidelines (as applicable). Maintains CPC and/or equivalent organization & CRC certification. Utilizes Internet resources for reviews and coding information. Reviews agency updates as issued.
- Identifies and refers quality of care issues identified in random reviews. Further researches chart to determine if further action should be taken, referring all issues to Assist Director. Available as a resource for non-clinical reviewers to assist in identifying these issues.
- Adheres to guidelines set by the clinic’s Compliance Program and Audit policy and procedures. Maintains confidentiality of all departmental information. Appropriate use of LCD to access only reviewed records.
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