Revenue Cycle Auditor - TMCOne

SUMMARY:

The Revenue Cycle Auditor is responsible for pre and post payment claim auditing of medical records and associated clinical documentation to ensure proper charge capture, billing in accordance with standard billing policies and reimbursement principles. This position is also responsible for assisting Revenue Cycle Services, HIM and other departments with resolution of billing issues and/or denials requiring clinical expertise, participating in external audit requests, and special projects as needed.  The Revenue Cycle Auditor also serves as an audit outcome educator with clinical staff in clinic and department settings.

ESSENTIAL FUNCTIONS:

Provides pre and post payment claim auditing of medical records and associated clinical documentation to ensure proper charge capture, billing in accordance with standard billing policies and reimbursement principles.

Responsible for assisting Revenue Cycle Services, HIM and other departments with resolution of billing issues and/or denials requiring clinical expertise, participating in external audit requests, and special projects as needed.

Provides leadership, direction, and oversight in developing policies and procedures, which support organizational goals and objectives related to employee programs.

Monitors and analyzes current industry trends and issues for potential organizational impact.

Provides clear short- and long-term direction, guidance, and leadership to staff, managers, and executive teams related to revenue benefits and audit findings. advice and recommendations.

Prepares detailed reports that provide a range of data to assist management in evaluating performance and making recommendations.

Provides technical guidance regarding interpretation of state, federal benefits legislation, ensures organizational compliance, and submits regulatory reports as required.

Develops contingency plans and responds to unforeseen circumstances utilizing planned resources.

Effectively assists with staff; interviews, trains; evaluates employee performance; delegates work assignments effectively.

Serves as an audit outcome educator with clinical staff in clinic and department settings

Adheres to TMCH organizational and department-specific safety, confidentiality, values, policies and standards.

Performs related duties as assigned.

Denials specific duties:

In addition to the essential functions the Revenue Cycle Auditor in denials will analyze denials data, tracking and trending denials and results.

Analyzes root causes of denials and reports findings as well as implements solutions with billers, coders, MA’s, and front desk staff. 

Meets with payers’ provider representatives to resolve incorrect payer denials and denials resulting from changes in payer policy.

Serves as a resource for billers and coders working denials.

Coding specific duties:

In addition to the essential functions the Revenue Cycle Auditor in coding will conduct chart audits on coders and offer education for coders’ compliance.

Analyzes provider claims data to identify audit risk.

Performs provider coding audits, educating providers on findings to increase provider compliance.

Serves as a resource for coders on coding guidelines and compliance to payer policies.

MINIMUM QUALIFICATIONS

EDUCATION:  Completion of a two (2) year college preferred or an equivalent combination of relevant education and experience.

EXPERIENCE: Minimum of three (3) years of experience in hospital or physician setting with extensive Revenue Cycle knowledge.  Minimum of two (2) years of audit experience with a concentration in High Balance and Cost Outlier and/or facility-based clinic audits

LICENSURE OR CERTIFICATION: For Denials - Certified Professional Biller (CPB) required.  For Coding - Certified Professional Coder (CPC) and Certified Professional Medical Auditor (CPMA) required. 

KNOWLEDGE, SKILLS AND ABILITIES:

·         Thorough knowledge of ICD and CPT application, correct practices, and tools utilized within the hospital or healthcare industry is required.

·         Knowledge of computer application software such as Microsoft Office products.

·         Skill in the developing procedures and training material

·         Skills with Health Information Management (HIM), Facility/Physician Billing, Charge Description Master (CDM), Denials Management, Charge Integrity, Financial Analysis

·         Ability to evaluate coding cycle performance and make recommendations for improvement.

·         Ability to read and interpret documents, medical records, contracts, proposals, and related legislation.

·         Ability to analyze, interpret, and prepare and present reports to management.