Inpatient Hospital Auditor II

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

14d•$79,100 - $105,945

About The Position

This position leads on-site audits of hospital billing and coding practices and desk audits. It develops forms, profiles and tracks institutional audit trends, designs audit protocols and special projects, and performs and finalizes multiple per diem, bill verification, DRG validation (utilization review) and credit balance audits. The role also provides guidance and instruction to stakeholders on ICD-9-CM, DRG assignment, payment and auditing. The auditor identifies and presents billing discrepancies, coordinates referrals of improper claim payments, analyzes error trends involving medical records, billing documentation and provider contract interpretation, and compiles audit statistics and information for accounts, regulatory agencies and internal requesters. The role reviews audit processes with the manager, trains new department staff, performs special assignments, and complies with applicable laws, regulations and policies.

Requirements

High school diploma or GED required.
A minimum of 3 years of experience in a medical records department of an acute care hospital or other health care facility.
Experience with DRG validation and ICD-9-CM training and education.
Knowledge of medical terminology, anatomy and physiology, disease pathogenesis and treatment, including procedural drug therapies, ancillary and diagnostic services.
Knowledge of utilization management principles, hospital structures and payment systems, and Centers for Medicare and Medicaid prospective payment system regulations.
Effective verbal and written communication skills and ability to work well within a team, including the ability to explain highly technical information to less technical individuals.
Strong PC skills and experience with Microsoft Office programs, including Excel, Word and PowerPoint.
Professional and ethical business practices, adherence to company standards, and commitment to personal and professional development.
Time management skills and ability to manage multiple priorities, deliver timely and accurate work with a customer-service focus, respond urgently as needed, and work in a production-focused environment.
Ability to ask probing questions and obtain thorough, relevant information.
Willingness to cross-train and be cross-trained in other roles and duties.
Detail orientation, strong organizational and data processing skills, ability to follow detailed instructions, and problem-solving skills.
Analytical and research skills.
Valid driver's license and access to a car.

Nice To Haves

Bachelor's degree in Health Information Management; relevant experience may substitute for the degree.
RN license.
RHIT or RHIA certification.
New Jersey Hospital Association membership.
CCS, CCS-P or CCA certification.
Knowledge of ACCESS Software.

Responsibilities

Lead on-site audits of hospital billing and coding practices and conduct desk audits.
Develop forms, profile and track institutional audit trends, and design audit protocols and special projects.
Perform and finalize per diem, bill verification, DRG validation (utilization review) and credit balance audits.
Provide guidance and instruction to stakeholders on ICD-9-CM, DRG assignment, payment and auditing.
Identify and present billing discrepancies found during audits and coordinate referrals of improper claim payments through appropriate channels.
Identify error trends related to medical records, billing documentation and interpretation of provider contract stipulations.
Compile statistics and other audit information for accounts, regulatory agencies and internal requesters.
Review and update audit processes with the manager to keep pace with innovations in clinical data review and company cost-containment initiatives.
Train new staff on department and audit procedures.
Perform other special assignments as requested by the manager.
Demonstrate knowledge of and conform to applicable laws, regulations and policies.