Lead Health Information Management Audit Specialist (On-Site)

Under direction from the Manager, Health Information Management, a Lead Health Information Management Audit Specialist collaborates closely with other departments and teams to provide efficient and thorough healthcare claims auditing for Beth Israel Lahey Health (BILH) and its affiliates. The Lead is responsible for third‑party audits of medical record data for reimbursement, regulatory compliance, quality, and appropriateness. The role includes medical record documentation review, training and education of colleagues, orientation, monitoring productivity and quality of work standards, updating workflow procedures, and assisting the manager in day‑to‑day activities. The Lead also processes and resolves complex audit compliance transactions. Job Description Assists the manager of the audit in planning and evaluating procedures that support the overall goals and objectives of the HIM and BILH audit processes. Prepares and reports the status and outcome of the various components of the Audit & Compliance section of HIM. Serves as a central communication audit resource to support requirements and proper follow‑up. Assists with overseeing adherence to standards for conducting audits and reviews for the HIM Department and BILH to ensure appropriate release of information in accordance with law and contractual obligations. Works closely with the Director of HIM as needed and the HIM Audit Manager to support new, regulatory compliance issues. Assists in the assignment of tasks and helps resolve technical and operational problems and provides direction and teamwork. Leads and assists with all audits for CMS, CERT, RACs, ADR, Quality, Medical Necessity, DRG insurers submissions, etc. Researches cases, transfers documentation to electronic media, updates the intra‑departmental database, communicates issues and findings to the Director of Internal Audit/Compliance, Director of Case Management, and Coding Manager as appropriate. Coordinates and follows the entire audit appeals process and supports reporting for tracking, financial and risk assessment. Coordinates BILH audits by leveraging Cobius Health for audit tracking and supports various workflows. Reviews billing/claims data in Epic. Researches and analyzes CMS requirements for billing to prevent revenue recoupment and advises the Director of Internal Audit and compliance on non‑compliant Physician Evaluation and Management coding/documentation. Serves as system administrator for Audit tracking system. Follows up and tracks the audit appeal process by monitoring report claims data for financial risks utilizing the audit management system. Prepares graphs and PowerPoint slides for reporting at various venues. Trains external and internal auditors on the navigation of a variety of systems necessary for the completion of audits, including Epic, BILH systems ECMS/Documentum. Possesses strong analytical and problem‑solving software skills. Works with Physicians, Billing, and Administrative personnel throughout BILH to formulate appeals to ensure BILH receives appropriate reimbursement or to correct documentation and billing practices to ensure compliance with Federal law and plan requirements. Provides documentation to the Referral Office to ensure proper billing and reimbursement of requested procedures and testing. Responds appropriately to miscellaneous requests from third‑party payors and the Patient Financial Services department to achieve proper reimbursement, satisfy contractual obligations, and assure compliance with regulations. Demonstrates competency and critical thinking in evaluating and prioritizing auditor requests. Can accurately explain to auditors the requirements and remedies necessary for incomplete requests and escalates as appropriate to manager. Maintains current knowledge base regarding new coding, compliance, and other regulatory issues. Coordinates other audits and projects as assigned by the Manager or assists in completing audits. Minimum Qualifications Education: Clinical background (RN or LPN) and/or HIM degree/Coding certification is strongly preferred, but equivalent working experience may be substituted. Experience: 3‑5 years of healthcare experience is required. Skills, Knowledge & Abilities Knowledge of medical terminology, anatomy and physiology, and general coding guidelines for reimbursement and healthcare processes. Experience using an EHR system, Microsoft Word and Excel. Excellent oral and written communication skills. Demonstrated ability to manage multiple projects simultaneously and independently. Pay Range $21.00 - $28.26 per hour (base hourly wage range). Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law. Equal Opportunity Equal Opportunity Employer/Veterans/Disabled #J-18808-Ljbffr Beth Israel Lahey Health