Revenue Integrity Compliance Auditor

Revenue Integrity Audits Support Specialist

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 staff 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.