Revenue Integrity Compliance Auditor

Department/Unit: AMHS Revenue Integrity

Work Shift: Day (United States of America)

Salary Range: $70,068.00 - $108,605.00

Under the direction of the Revenue Integrity Audits Manager, this position is responsible for providing audit and research support to physicians, advanced practice professionals, professional fee billing staff, clinic staff, administrators, and other affected personnel on documentation and billing requirements. Using established auditing and research techniques, determines the adequacy of medical records documentation, coding and billing for all providers across all clinical specialties. This position reads, interprets, and distributes coding and billing guidelines to all departments to ensure regulatory compliance.

Essential Duties and Responsibilities

Exemplifies the AMHS Values and Code of Conduct, while striving to identify compliance risk through effective and timely review of RAC Audit requests, ensuring timely appeals, as appropriate, and reporting any identified risks to Legal Services and Corporate Compliance Departments.

Ensures immediate action is taken on any issues identified by Legal Services or Corporate Compliance.

Builds and nurtures collaborative supporting relationships with the AMHS executive team, clinical chairs, faculty, clinicians, and other leaders across the health system and encourages, promotes, and advocates staff to ensure integration of new processes across all departments.

Review clinical documentation within the patient medical record and charges in financial system in response to edits and/or inquiries from third-party payers

Resolves edits based on regulatory and/or payer specific guidelines

Generates appeal letters in response to denials received from payers and updates information in patient accounting system to reflect actions taken

Works collaboratively with members of the revenue cycle, information systems and clinical departments toward ensuring accuracy of charges on patient accounts

Performs audits on patient accounts as requested and tracks results for ongoing review by revenue cycle performance improvement and/or leadership

Engages in end-to end testing scenarios as needed to ensure new charge generation and/or revisions are accurate within the information system and populate correctly in the financial billing system

Performs review of clinical documentation within the electronic medical record and validates and/or add charges to patient encounter as appropriate

Research and answers billing and documentation questions or problems submitted by faculty, advanced practice professionals, departments, billing staffï and others to ensure compliance with specific payer regulations

Reviews documentation or coding patterns by a clinician, division or department that poses a compliance risk and provides input on recommended solutions

Keeps current with third party regulations with emphasis on Medicare billing, teaching physician regulations, Current Procedural Terminology, ICD-IO-CM Coding, and professional fee billing.

Acts as source of reference for enterprise on regulatory, reimbursement or billing changes, and develops and implements training to maintain and support compliance with federal and state regulations.

Maintains a working knowledge of revenue cycle process to aid in the implementation of regulatory standards that assist compliant charge capture practices.

Monitors compliance with corporate, federal, and state guidelines to include review of commercial bulletins for HCPCS/CPT code changes and additions and billing unit rule changes.

Performs other duties as assigned.

Qualifications

Associate's Degree in health care-related or business-related field - required

Bachelor's Degree in nursing - preferred

Two years of experience in auditing, compliance and/or coding - required

Minimum of three years' experience in a clinical setting - preferred

Epic experience - preferred

Knowledge of third-party billing regulations for hospital and/or provider reimbursement

Experience and understanding of the CPT coding system

Knowledge of medical necessity edits related to local and national coverage determinations(LCDs and NCDs), correct clinical initiatives (CCls) and medically unlikely edits (MUEs)

Strong clinical knowledge and clinical documentation practices

Excellent verbal and written communication skills

Experience with navigating within the electronic medical record, experience with Epic preferred

Strong critical thinking skills

Detail oriented and ability to prioritize multiple tasks/projects when varying deadlines

Engaged and collaborative team player, contributing to the overall success of team

Experience utilizing MS office products

RHIT, RHIA, CCS, or CPC - required

Registered Nurse (RN) - preferred

Equivalent combination of relevant education and experience may be substituted as appropriate.

Physical Demands

Standing - Occasionally

Walking - Occasionally

Sitting - Constantly

Lifting - Rarely

Carrying - Rarely

Pushing - Rarely

Pulling - Rarely

Climbing - Rarely

Balancing - Rarely

Stooping - Rarely

Kneeling - Rarely

Crouching - Rarely

Crawling - Rarely

Reaching - Rarely

Handling - Occasionally

Grasping - Occasionally

Feeling - Rarely

Talking - Constantly

Hearing - Constantly

Repetitive Motions - Frequently

Eye/Hand/Foot Coordination - Frequently

Working Conditions

Extreme cold - Rarely

Extreme heat - Rarely

Humidity - Rarely

Wet - Rarely

Noise - Occasionally

Hazards - Rarely

Temperature Change - Rarely

Atmospheric Conditions - Rarely

Vibration - Rarely

Thank you for your interest in Albany Medical Center!

Albany Medical Center is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Thank you for your interest in Albany Med Health System!​

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.