Compliance Auditor - Hospital IP/OP

Baptist Health Care
United States, Florida, Pensacola
Dec 22, 2024
Job Description This Compliance Auditor - Hospital IP/OP is responsible for auditing inpatient claims to federally funded healthcare payors across all Baptist Health Care (BHC) inpatient facilities. The position audits and provides feedback as needed and attends inpatient (IP) 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 position 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; accurately reflects mortality; and maximizes reimbursement. The Compliance Auditor - Hospital IP/OP requires a keen eye for detail, excellent communications and critical thinking skills, and a commitment to maintaining the highest ethical standards. This position is onsite in Pensacola, FL. Responsibilities Audits inpatient (IP) 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 inpatient 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. Maintains responsibility 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 care compliance experience including coding compliance Required and 3 years Health care compliance auditing of coding and billing practices Required 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 Coding Specialist (CCS_AHIMA) Upon Hire Required or Certified Coding Specialist-Physician-based (CCSP_AHIMA) Upon Hire Required or Certified Professional Coder (CPC_AAPC) Upon Hire Required or Certified Outpatient Coding (COC_AAPC) Upon Hire Required or Certified Professional Medical Auditor (CPMA_AAPC) Upon Hire Required Required Skills, Knowledge and Abilities Strong knowledge of ICD-10/PCS/CPT/HCPCS coding and billing compliance (MS-DRGs/IPPS, 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.