Quality Assurance Clinical-Billing Auditor-QA535206

divh2Quality Assurance Clinical-Billing Auditor-QA535206/h2pJob Category: Human/Social Services Requisition Number: QUALI008027/ppFull-Time Salary: $76,000 USD per year/ppDepartment of Quality 125 Broad St New York, NY 10004, USA/ph3Description/h3pstrongJob Summary/strong/ppThe Clinical and Billing Auditor is responsible for the oversight and management of auditing and monitoring activities across the organization. Using a unique combination of clinical expertise and billing knowledge, this role monitors and improves the quality of clinical and financial documentation related to patient services. The auditor compares clinical and financial records to ensure that provided documentation supports the charges listed, helping to mitigate errors, prevent fraud, and optimize appropriate reimbursement./ppstrongEssential Job Functions:/strong/pullistrongReviewing Documentation:/strong Audit clinical documentation, treatment plans, and progress notes as well as utilization reviews to ensure accuracy, completeness, and compliance with billing requirements, regulatory quality standards, and diagnostic criteria for ICL outpatient programs./lilistrongMonitoring Program Effectiveness:/strong Evaluate the effectiveness of mental health and intellectual disabilities programs in achieving desired outcomes, such as symptom reduction, functional improvement, and enhanced quality of life for individuals served. Identify opportunities for program enhancement based on audit findings and performance metrics./lilistrongAssessing Clinical Quality:/strong Evaluate the quality and appropriateness of clinical care provided to individuals with mental health conditions. including assessment, diagnosis, treatment planning, and therapeutic interventions. Ensure adherence to evidence-based practices and ethical standards./lilistrongIdentifying Training Needs:/strong Identify training needs and provide education and support to clinicians, staff, and providers on topics related to billing compliance, documentation standards, diagnostic criteria, treatment modalities, and best practices in ICL outpatient programs./lilistrongCollaborating with Multidisciplinary Teams:/strong Participation in managing clinical risks in the agency by participating in Incident Review Committee Meetings, High Risk Meeting, and Sentinel Reviews, Psychiatric Medical At-Risk Case conference. Work collaboratively with clinical teams, including psychiatrists, psychologists, social workers, therapists, and case managers, to ensure coordinated and integrated care for the clients with ICL outpatient programs and intellectual disabilities. Participation in managing clinical risks in the agency by participating./lilistrongRisk Management Compliance Oversight:/strong Identify high risk areas for fraud, waste and abuse. Escalate significant compliance concerns. Support organizational readiness for external audits, payer investigations./lilistrongRate Billing Accuracy Validation:/strong Ensure correct application of fee schedules and rate codes. CPT/HCPCS codes (where applicable. Cross-check billed services against Program type, staff credentials, service duration, and monitor adherence to payer-specific billing requirements./lilistrongRegulatory Recovery and Risk Mitigation:/strong Consult with division administrators to develop and execute quality improvement plans, including plans of corrective action (POCAs) for certification visits and internal agency audit reports./lilistrongOperational Integration:/strong Participate in program planning projects and meetings to provide inputs on development of quality control and program evaluation elements; and conduct or participate in management meetings with service-delivery staff to establish, delineate, and review program organizational policies, to coordinate functions and operations between departments, and establish responsibilities and procedures for attaining objectives and assist with the implementation of new programs./lilistrongStaying Informed:/strong Stay updated on changes in healthcare regulations, billing requirements, reimbursement policies, and quality assurance standards relevant to mental health and intellectual disabilities services. Maintain knowledge of emerging trends, research findings, and best practices in the field./liliPerform other related duties as assigned./li/ulpstrongEssential Knowledge, Skills and Abilities:/strong/pulliCommitted to the active promotion of ICL values and goals./liliDemonstrated mastery of ICD-10-CM, CPT, and HCPCS codes./liliProficiency in Electronic Health Records (EHR) systems and advanced Microsoft Excel skills for data analysis./liliA solid understanding of HIPAA, Medicaid/Medicare billing rules, and documentation standards./liliKnowledge of relevant industry regulations and compliance standards to ensure adherence to legal and ethical guidelines./liliAbility to collaborate effectively with individuals at all levels of the organization./liliAbility to educate staff on compliance issues and quality improvement continuous measures./liliStrong organizational skills to manage multiple audits, prioritize tasks, and meet deadlines./liliExcellent verbal and written communication skills./liliAbility to identify risks related to client safety, compliance, and quality of care./liliAbility to analyze information objectively and form a reasoned judgment./liliA keen eye for detail for identifying inconsistencies, errors, and areas of non-compliance./liliAbility to make sound judgments and decisions based on evidence and analysis./liliAbility to adapt and willing to learn new techniques and technologies./li/ulpstrongQualifications and Experience:/strong/ppMasters degree in social work, or Psychology, or related field plus 2 years experience in a clinical or human services environment conducting assessments or evaluations, performing quality assurance work, or managing programs. Certification: CPMA (Certified Professional Medical Auditor) or CHC (Certified in Healthcare Compliance) or CPB (Certified Professional Biller) designation strongly preferred./ppEqual Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor./p/div