Billing Compliance Auditor

Nicklaus Children's; Homestead (FL); Sur place; USD 95 000 - 120 000; Plein temps

Résumé du poste

Nicklaus Children’s Hospital in Florida seeks a Billing Compliance Auditor to audit coding and documentation for professional and facility services, ensuring compliance with federal, state, and local regulations as well as hospital policies.

Responsibilities include auditing CPT/ICD-10, validating E/M levels, DRG reviews, and conducting quality assurance for payer submissions. Strong CMS/Medicaid knowledge and data-mining audit experience are required.

Qualifications

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

Responsabilités

• Audits professional and facility billing coding for compliance.
• Reviews E/M level, CPT, ICD-10 and modifiers per AMA and CMS.
• Performs DRG coding reviews and validates clinical indicators.
• Conducts quality assurance for billing to federal/state payers.
• Analyzes review outcomes and identifies high-risk areas.
• Develops CAPA recommendations and documents findings in the system.
• Keeps current on national/local coding and billing decisions.
• Performs follow-up audits to verify remediation.
• Supports RAC and external recoupment requests review.

Connaissances

Auditing

Healthcare coding

Data analysis

CMS regulations

Communication

Formation

CPC/CCS/RHIA/RHIT certification

Bachelor's degree preferred

Outils

EPIC

Description du poste

Billing Compliance Auditor-302144

Description

Job 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.

Qualifications

Minimum 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

: Professional

Primary Location

: Florida-Miami-Nicklaus Children’s Hospital – Main Hospital Campus

Department

: COMPLIANCE-1000-910900

Shift

: Days

Job Status: Full Time