Profee Remote Auditor/Educator

Presbyterian Healthcare Services

1d • Remote

About The Position

Presbyterian is hiring a skilled Profee Remote Auditor/Educator to join our team. This full-time, exempt position is based remotely for workers in New Mexico and operates on a day shift. The role directly supports the Coding and Documentation Quality Assurance (CDQA) team by implementing and ensuring compliance with enterprise-wide coding policies and procedures, as well as external regulatory agency rules. The position involves performing internal audits, serving as a resource for documentation, coding, billing, and compliance questions, working on special projects, developing and presenting educational programs, and creating educational tools to maintain regulatory compliance. Additionally, it involves auditing and training low-performing personnel, reviewing denied and appealed claims, and researching regulatory information. The role requires maintaining accurate documentation, adapting to changing priorities, and staying updated on legal and regulatory information, including ICD-9, ICD-10, CPT-4, HCPCS, and APC updates. It also involves identifying risks, developing action plans, identifying revenue opportunities or overpayments, and providing compliance education. The position contributes to the CDQA Annual Audit Work-plan and exercises independent judgment in data reliability and recommending practice changes. The role requires responding to daily inquiries, maintaining knowledge of IT applications, gathering and analyzing information, and conducting training classes on coding, documentation, and compliance for PHS/PMG personnel. This includes preparing training materials, conducting educational audits, and providing ICD-10 and EPIC EMR documentation education. The role also involves conducting systematic focused internal audits, analyzing and summarizing audit data, communicating findings, and developing methods to improve coding efficiency. The position requires researching customer concerns, ensuring coding functions meet quality standards, and may involve travel to PHS/PMG sites, including overnight stays.

Requirements

• High school diploma/GED required.
• Must possess at least one of the following license/certifications: RHIT, RHIA, CPC, CCS.
• A minimum of three (3) years experience in coding and/or auditing required.
• Excellent written and verbal communication skills.
• Detail and results oriented.
• Ability to work independently and make independent decisions.
• Medical terminology, ICD-9, CPT-4 and HCPCS knowledge required.
• Must have a proficient knowledge of Medicare, Medicaid, and other third party payer documentation, coding, and billing regulations for service lines(s) assigned.
• Must possess excellent organizational and planning skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously.
• Must possess computer skills, especially with Microsoft Word, PowerPoint, and Excel applications.
• Must be able to use the internet and other resource applications for research purposes and to provide documentation that supports regulations quoted in audits.
• Must possess strong written and verbal communication skills in order to communicate in clear, concise terms to management at all levels, including the ability to articulate complex regulatory information in laymans terms.
• Must possess a personal presence of a highly qualified professional that is characterized by a sense of honesty, integrity, and the ability to inspire and motivate others.

Nice To Haves

• Audit experience preferred.

Responsibilities

• Implementation of and compliance to enterprise-wide and department coding policies and procedures for PHS.
• Compliance to all external regulatory agency coding rules and regulations.
• Performing and/or managing on-site internal audits or reviews to assess compliance/quality monitoring performed by PHS/PMG departments.
• Serving as a resource on documentation, coding, billing, and coding compliance questions.
• Working on special coding compliance related projects.
• Developing and presenting educational programs.
• Disseminating information to PHS/PMG departments.
• Developing educational tools used to maintain compliance with regulations.
• Providing support via auditing and training the enterprise-wide corrective action plans for coding, audit, physician and clinician personnel identified as low performers.
• Performing medical record and billing reviews of denied and appealed claims and taking appropriate action to ensure accurate payment of claims.
• Coordinating review and tracking of appealed claims including the communication process with affected payers.
• Researching and interpreting all regulatory agency regulations.
• Acting as a liaison to the Manager, Information Services, Finance/Patient Financial Services, all hospitals, all PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance and all ancillary departments in addressing functional coding, auditing, compliance and training issues and problems.
• Interacting with all levels of management.
• Maintaining accurate, complete and timely documentation in either electronic or hard copy form.
• Adapting to frequently changing work priorities and schedules.
• Maintaining and disseminating up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area.
• Researching, billing and charging compliance issues, recommending and implementing corrective action plans that assure compliance with regulatory agencies where appropriate.
• Identifying risks, developing and following up on action plans, identifying lost revenue opportunities and any overpayments due to errors in coding and/or documentation, and providing compliance education.
• Assisting in the creation of the CDQA Annual Audit Work-plan by utilizing the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, as well as internal and external risk assessments.
• Regularly exercising independent judgment in determining the reliability of data reviewed; recommending changes in existing practices to gain or maintain compliant behavior.
• Keeping actively informed on the business climate of the healthcare industry.
• Responding to inquiries and requests daily regarding coding and auditing issues and problems and ad-hoc analysis for all PHS management.
• Maintaining up-to-date working knowledge of all PHS coding and auditing IT applications.
• Gathering and analyzing information and providing recommendations to address and resolve business issues for a specific business group.
• Conducting training classes in areas of coding, documentation and compliance for PHS/PMG personnel.
• Conducting systematic focused internal audits via medical record and charge ticket review to insure correct coding, billing and charging as member of CDQA audit team.
• Analyzing and summarizing data from medical record and account audits and communicating results and findings to management and compliance.
• Developing new methods and processes to improve coding efficiency and effectiveness.
• Researching and investigating external and internal customer concerns regarding patient care and/or billing of patient care.
• Ensuring that coding functions are performed in accordance with established quality and performance standards by monitoring system generated reports and quality audits.

Benefits

• Medical
• Dental
• Vision
• Short-term and long-term disability
• Group term life insurance
• Other optional voluntary benefits
• Wellness rewards program (earn gift cards and more by participating in wellness activities like wellness challenges, webinars, preventive screenings, etc.)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED