Billing Compliance Auditor

Nicklaus Children's Hospital Careers; Florida; On-site; USD 90,000 - 130,000; Full time

Job summary

Nicklaus Children's Hospital is seeking a Billing Compliance Auditor to support the NCHS Billing Compliance Program. You will audit coding and documentation for professional and facility services to ensure adherence to federal, state, and local regulations and the hospital's policies.

This role conducts audits of E/M levels, CPT, ICD-10, and modifiers per AMA/CMS guidelines, performs DRG reviews, and supports corrective action plans.

Qualifications

• CPC, CCS, RHIA, or RHIT certification required.
• 7-10 years of experience in coding and auditing of professional fee and facility fee services.
• 7-10 years of experience with CMS and Florida Medicaid regulations, including billing, coding and documentation requirements.
• 2-4 years of experience with conducting data mining audits.

Responsibilities

• Conducts coding and documentation audits for professional fee and facility services.
• Conducts audits for validation of appropriate E/M level, CPT, and ICD-10, Modifier appropriateness according to current AMA and CMS guidelines.
• Conducts DRG coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with CMS / federal requirements.
• Conducts quality assurance activities to ensure the accuracy and integrity of billing submitted to Federal and State payers.
• Analyzes Billing Compliance review outcomes and proactively identifies trends and high-risk areas.
• Develops appropriate recommendations for Corrective and Preventative Action (CAPAs).
• Documents finding in the case management system as part of the CAPAs.
• Researches changes in national and local coding and billing coverage decisions: maintains current knowledge of appropriate billing procedures.
• Performs follow-up audits to ensure remediation of findings.
• Supports the review and analysis of Recovery Audit Contractors (RAC) requests and other external requests for recoupment.

Skills

Auditing

Coding compliance

Regulatory knowledge

Data mining

Education

CPC/CCS/RHIA/RHIT certification

Bachelor's degree (preferred)

Tools

EPIC

Job description

DescriptionJob Summary

Serves as a resource to the NCHS Billing Compliance Program and is responsible for auditing coding and documentation for professional fee and facility services to ensure compliance with federal, state and local regulations, and NCHS policies.

Job Specific Duties

• Conducts coding and documentation audits for professional fee and facility services.
• Conducts audits for validation of appropriate E/M level, CPT, and ICD-10, Modifier appropriateness according to current AMA and CMS guidelines.
• Conducts DRG coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with CMS / federal requirements.
• Conducts quality assurance activities to ensure the accuracy and integrity of billing submitted to Federal and State payers.
• Analyzes Billing Compliance review outcomes and proactively identifies trends and high-risk areas.
• Develops appropriate recommendations for Corrective and Preventative Action (CAPAs).
• Documents finding in the case management system as part of the CAPAs.
• Researches changes in national and local coding and billing coverage decisions: maintains current knowledge of appropriate billing procedures.
• Performs follow-up audits to ensure remediation of findings.
• Supports the review and analysis of Recovery Audit Contractors (RAC) requests and other external requests for recoupment.

QualificationsMinimum Job Requirements

• CPC, CCS, RHIA, or RHIT certification required
• 7-10 years of experience in coding and auditing of professional fee and facility fee services
• 7-10 years of experience with CMS and FL Medicaid regulations, including billing, coding and documentation requirements
• 2-4 years of experience with conducting data mining audits

Knowledge, Skills, and Abilities

• Bachelor's Degree preferred.
• Experience with EPIC is preferred.
• Experience in conducting Hospital, Professional Fee Service billing and coding audits preferred.
• Able to work independently.
• Able to research, abstract and communicate federal, state and payer documentation, billing and coding rules and regulations.
• Ability to be flexible, multitask, and switch priorities as well as work comfortably in a deadline driven/productivity environment.
• Ability to prioritize, organize, plan, and implement services as well as handle multiple projects/problems simultaneously.
• Excellent written and verbal communication skills.
• Excellent time management and organization skills.
• Strong interpersonal, collaboration, and presentation skills.
• Able to use tact, diplomacy, discretion, and judgment.
• Able to maintain confidentiality of sensitive information.

Job:ProfessionalDepartment:COMPLIANCE-1000-910900Job Status:Professional