Billing Compliance Auditor

Nicklaus Children's Hospital Careers; Miami (FL); On-site; USD 90,000 - 130,000; Full time

Job summary

Nicklaus Children's Hospital Careers seeks a Billing Compliance Auditor to support the hospital's Revenue Cycle by auditing professional and facility services for coding and documentation accuracy. This role ensures compliance with federal, state, and local regulations and hospital policies.

Responsibilities include auditing E/M levels, CPT/ICD-10/Modifier usage per AMA and CMS guidelines, DRG reviews, and QA of billing submitted to payers.

Qualifications

• 7-10 years of experience in coding and auditing professional fee and facility services.
• 2-4 years of experience with data mining audits.
• Bachelor's degree preferred; strong communication and independent work abilities.

Responsibilities

• Audits coding and documentation for professional fee and facility services.
• Audits validation of E/M level, CPT, ICD-10, and Modifier usage per AMA/CMS guidelines.
• Performs DRG coding reviews to verify accuracy and indicators for CMS requirements.
• Conducts quality assurance to ensure billing accuracy for federal/state payers.
• Analyzes review outcomes to identify trends and high-risk areas.
• Develops CAPA recommendations and documents findings in the case management system.
• Researches changes in coding and billing decisions; stays current on regulations.
• Performs follow-up audits to verify remediation of findings.
• Supports RAC requests and other external recoupment requests.

Education

CPC, CCS, RHIA, RHIT certification

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.

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