Compliance Auditor Senior

Highmark Health • PA, Working at Home - Pennsylvania, PA

5d • $34 - $54

About The Position

The Senior Auditor is responsible for clinical or physician compliance topics, handling the most complex clinical, documentation, coding, and billing reviews. This role provides guidance to other auditors within AHN on audit approaches and analysis, is responsible for creating and overseeing auditor orientation, and leads all hospital or physician audits, investigations, auditing support, and responses related to external audit activity.

Requirements

• 7 years in utilization review, case management, hospital/physician coding and documentation audits/reviews
• Experience with medical necessity denials/appeals
• Bachelor's degree in nursing (For Compliance Auditor - Sr. (Clinical Specialty))
• Bachelor's degree or equivalent education and related experience (For Compliance Auditor - Sr. (Clinical Specialty AND Physician Specialty))

Nice To Haves

• Master’s degree (For Compliance Auditor - Sr. (Clinical Specialty))
• RHIT, RHIA certification (For Compliance Auditor - Sr. (Physician Specialty))
• Knowledge of a variety of clinical specialty areas, practices and procedures as well as 340B program

Responsibilities

• Establishes and implements orientation for all members of the AHN audit compliance team.
• Evaluates the progress of team members including review of reports and audit activities.
• Works with senior management responsible for AHN-wide case management/physician programs to develop processes that meet Medicare and 3rd party payor requirements.
• Provides guidance to staff auditors on audit topics and reports.
• Conducts educational sessions for hospital/physician staff.
• Conducts investigations and performs special projects as assigned.
• Audits/oversees the auditing of the 340B program and provides guidance to the 340B management team (Clinical Specialty).
• Participates in meetings specific to case management/UR and assists with 340B regulatory requirements and monitors corrective actions when needed (Clinical Specialty).
• Analyzes and summarizes PEPPER reports and recommends high risk areas for audit (Clinical Specialty).
• Conducts audits of Medicare/Medicaid and other third party payor accounts for documentation, medical necessity, coding (non DRG), charging, billing and compliance with state and federal regulations (Clinical Specialty).
• Prepares accurate and concise written audit reports (Clinical Specialty).
• Works with auditees on corrective action plans and educates management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, coding requirements (Clinical Specialty).
• Responds to external audits of the government (facility based) sent to the compliance office and works with operational owners to establish and implement corrective actions when needed (Clinical Specialty).
• Advises UR/CM in defending payor claims denials for medical necessity, coding, billing and documentation through coordination of and/or participation in the appeal process (RACS, ZPICs, MICs and OIG audits in particular and other payors as assigned) (Clinical Specialty).
• Analyzes E&M bell curve reports and recommends high risk areas for audit (Physician Specialty).
• Manages the database of new providers and assigns for audit/education to team members (Physician Specialty).
• Participates in meetings specific to physician coding, billing and documentation and monitors corrective actions when needed (Physician Specialty).
• Performs internal concurrent, prospective, and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding and documentation is compliant with appropriate guidelines and federal and state regulations (Physician Specialty).
• Develops audit detail summary spreadsheets and reports to address any coding, documentation, or financial discrepancies (Physician Specialty).
• Conducts presentations of final audit findings to department staff, physicians, and appropriate individuals (Physician Specialty).

Benefits

• Adherence to ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
• Compliance with HIPAA as described in the Notice of Privacy Practices and Privacy Policies and Procedures.
• Compliance with all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
• Compliance with the company’s Code of Business Conduct, including adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior