Compliance Auditor - OP/Ambulatory Services

Job Description

The Compliance Auditor - OP/Ambulatory Services is responsible for auditing outpatient and ambulatory services claims to federally funded healthcare payors across the Baptist Physician Enterprise (BPE) organization. The position audits and provides feedback and attends BPE department meetings as needed to respond to compliance related coding and billing questions and provide feedback on audit findings and necessary remediation/corrective action requirements. The position analyzes coded records for compliance with federal, state and third-party insurer rules and regulations and note trends. The Compliance Auditor - OP/Ambulatory Services educates physicians and staff on error trends and how to prevent/reduce errors to demonstrate compliance with the False Claims Act, the Federal Overpayment Rule, CMS and Medicaid billing and coding requirements to maximize reimbursement.

This position is onsite in Pensacola, FL.

Responsibilities

• Performs routine and targeted audits of inpatient services and corresponding claims submitted to government payors.
• Audits outpatient (OP)/ambulatory service claims to assure a minimum of 95% accuracy and recommends corrective action, education, and training related to audit results.
• Audits the assignment of International Classification of Diseases 10-CM (ICD-10) diagnostic and ICD-10-PCS procedural codes, Current Procedural Terminology (CPT) codes with modifiers, and other applicable codes in an accurate and productive manner on sampled outpatient/ambulatory cases.
• Reviews, analyzes and abstracts physician/other documentation for diagnoses, procedures, ancillary testing, medications, laboratory and other services provided.
• Utilizes Healthicity or other compliance and audit systems, develops and maintains comprehensive audit reports and documentation of each audit performed, cases sampled, and audit findings.
• Meets with audited providers/department leadership to present audit findings and required remediation/corrective actions to cure coding and billing errors; effectively educates and promotes awareness of compliant billing and coding requirements.
• Provides information to physicians and other health care staff regarding current coding practices and changes in state and federal regulations and guidelines.
• Researches and resolves problems referred by auditees and provides prompt feedback
• Serves as a subject matter expert and resource for information and clarification on accurate and ethical coding and auditing processes and demonstrates a thorough knowledge of coding guidelines, governmental regulations, and billing requirements.
• Participates in and provides education sessions as needed on specific coding topics at huddle meetings and other forums.
• Communicates with physicians and other health care staff to obtain missing information or to clarify existing information.
• Responsible for the identification of claims that require correction or other reimbursement related remedies to cure coding and billing errors identified through audit activities.
• Responsible for operational excellence; ensures the delivery of quality audit services in accordance with applicable policies, procedures, and professional standards.
• Assist in other duties as assigned to support the operational needs of the department and organization
• May be required to remain on campus immediately before, during, and after severe weather and/or disasters

Qualifications

Minimum Education

• Bachelor's Degree Health Information Management, Five years of related experience maybe considered in lieu of degree, Other related field Required

Minimum Work Experience

• 5 years Health experience Required
• 1-3 years Health care coding and billing experience Preferred
• Experience with the following applications and systems: Healthicity, Altera Sunrise (formerly Allscripts), Hyland MRM, Clintegrity, FinThrive, and MS Office Suite and Excel in particular Preferred

Licenses and Certifications

• Certified Professional Coder (CPC_AAPC) within 1 Year Required and
• Certified Professional Medical Auditor (CPMA_AAPC) within 2 Years Required

Required Skills, Knowledge and Abilities

• Strong knowledge of ICD-10/PCS/CPT/HCPCS coding and billing compliance (APC/OPPS) with excellent analytical and data mining skills.
• Ability to effectively participate and supervise projects, plan and implement programs, and evaluate outcomes.
• Ability to effectively work directly with various levels of staff (including on-site and remote).
• Must possess strong communication skills, both written and verbal.
• Exhibits effective organizational skills, time management, and management of multiple priorities.
• Ability to make effective and persuasive presentations on complex topics to management and physicians.
• Ability to teach and mentor coders and physicians on complex coding systems.
• Ability to have an excellent balance of being highly productive and yet produce high quality work.
• Must be able to create strong arguments based on solid coding guidelines and audit practices.
• Ability to interpret federal and state regulations as they relate to coding and compliance.

About Us

Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida.