Rev Integrity Auditor Sr

Covenant Health•Knoxville, TN

5d•Onsite

About The Position

Performs complex level professional internal auditing work. Work involves compliance audit projects for Covenant Health entities as they relate to charging, coding, documentation and compliance. This would include E/M, procedure, and ICD-10 reviews, as well as any needed provider or staff education. Also provides consulting services to the organization’s management and staff and may participate in requested investigations. Maintains all organizational and professional ethical standards. Works independently under limited supervision with significant latitude for initiative and independent judgment. Performs other duties as needed. Reports to the Revenue Integrity Manager.

Requirements

Five (5) years’ experience in health care.
Good working knowledge of healthcare billing, Medicare/Medicaid billing guidelines, and other Third Party Payor rules and Regulations.
Experience in problem solving, analytical reviews,
Must be knowledgeable in use of PC's, Windows, Excel and Word Processing;
Must have good public relations skills.
Must have certification (RHIT, RHIA, CCS or CPC) in field of healthcare related study or current clinical license/registration in the State of Tennessee as RN with equivalent coding experience.

Responsibilities

Identifies and evaluates company risk areas and provides auditing procedures related to documentation and reimbursement to include: documenting client processes and procedures; assessing risks and adequacy of related manual and automated internal controls; developing criteria; reviewing and analyzing findings. Also provides corporate oversight of any current departmental audit programs.
Reviews ADR log, Appeals Database and Payor websites to identify audit issues and proactively trend data.
Reviews and studies all information published by CMS and the OIG via the Federal Register, fraud alerts, OIG advisory opinions, and other publications relative to coding, billing and reimbursement compliance in order to ensure compliance.
Reviews information from third party payers relative to claims charging, coding, and billing in order to ensure compliance.
Performs research and analysis of charges, CPT coding, modifiers and billing processes to ensure compliance with Medicare, Medicaid guidelines and other insurance payors and to maximize reimbursement.
Explains charges and charging procedures to third party insurance companies for defense audits as applicable.
Coordinates with appropriate parties the complete/ partial payment or repayment of the claims, as described in the Audit Policy, as findings are identified that are either over-payments or underpayments.
Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to management and audit committee.
Documents all audit activities in a designated location; reports statistics and identified problems monthly or more urgently if deemed necessary.
Monitors audits performed at the department level in order to ensure that data is appropriate, is being maintained and is being disseminated to leadership as indicated.
Assists with payor denials when necessary.
Assists with special projects and performs other duties as needed and requested by the Vice President of Patient Account Services and Corporate Manager of Revenue Integrity.
Supports, models and adheres to the desired behaviors of the KBOS Constitution for quality which are; celebrate and reward successes, seek out better ways to do our job, set improvement goals and standards striving to meet or exceed them, participate in forming and being part of work teams when necessary and do not say "It's not my job.”
Works in conjunction with health information management, patient accounting, information systems and other personnel to assist with implementation of solutions to maintain a proper compliance stance.
Under the direction of Revenue Integrity Manager, works with the Manager of Revenue Processes to assist with implementation of solutions to maintain a proper compliance stance.
Under the direction of Revenue Integrity Manager, works with the Chief Compliance Office relative to coding, billing and reimbursement compliance issues.
Under the direction of Revenue Integrity Manager, works with the Chief Compliance Officer in the development and ongoing activities involved in the baseline and periodic compliance audits and compliance programs as deemed appropriate by manager.
Works with contract management personnel in the review of contracts and other reimbursement or payment arrangements in relation to charging, coding and billing compliance.
Works closely with Financial Analysts to identify process improvement activities and audit opportunities.
Provides leadership to the audit and appeals team and assists with training of coworkers to include new employee orientation, systems overview and production of written deliverables.
Advises, educates and acts as clinical/billing liaison between CFOs, department managers and billing staff to maximize reimbursement within compliance guidelines for Medicare, Medicaid and other insurance payors as deemed appropriate by manager in relation to audit findings and process improvement initiatives.
Coordinates and facilitates problem resolution sessions where multiple departments and/or service areas are involved as deemed appropriate by manager.
Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.
Maintains lines of communications with Facilities in an ongoing effort to improve the overall quality of customer service.
Promotes good public relations for the department and the Finance Division.
Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability and professionalism.
Supports, models and adheres to desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.
Maintains professional growth and development through continuing education, seminars, and applicable professional affiliations to keep informed of industry trends.
Demonstrates ability to successfully locate, interpret and apply regulations with which they may be otherwise unfamiliar.
Demonstrates consistent aptitude in performing with minimal supervision and oversight while making independent decisions.
Recognizes situations, which necessitate supervision and guidance, while seeking and obtaining appropriate resources.
Independently prioritizes daily work functions/tasks ensuring all assigned deadlines are met.
Coordinates with staff to ensure necessary materials, equipment and/or supplies are maintained utilizing all avenues of resource management in ordering supplies for departmental needs.
Utilizes resources available appropriately, i.e. use of Covenant Health equipment and/or supplies.
Does not promote or participate in solicitation during working hours within the department.
Supports, models and adheres to the desired behaviors of the KBOS Constitution for using the community’s resources wisely which are; be aware of cost and quality when making spending decisions, demonstrate a personal commitment to reduce waste, consider the impact on other departments and facilities within Covenant Health when making decisions or taking action and ensure that meetings lead to solutions.