Premium Management Pre-Audit Manager

MCS Puerto Rico; San Juan (PR); On-site; USD 80,000 - 100,000; Full time

Job summary

MCS Puerto Rico is seeking an experienced professional to guarantee timely internal and external audits of Independent Contractors and Providers within the unit’s program. You will monitor the work plan for clinical coding audits and supervise personnel across operational areas, guiding improvements to risk areas identified by CMS risk adjustment audits.

The role requires a Bachelor’s degree in healthcare administration or related field, at least five years of audit experience, and supervisory

Qualifications

• Bachelor’s degree in Healthcare Administration or related field with at least 5 years auditing diagnosis coding.
• Experience supervising personnel and reviewing medical records.
• Certification in Medical Billing, CPC, or CCS preferred.

Responsibilities

• Develops and updates annually the work plan for audits of internal coding team and contractors.
• Oversees clinical coding audits and evaluates results to design improvement strategies.
• Guides Providers, IPAs, and Medical Office Billing Representatives on coding practices and documentation.
• Ensures procedures and records for audits and corrective actions are up to date.
• Monitors implementation of action plans and improvement efforts identified in audits.
• Prepares and submits reports to management on audit findings per the work plan.

Skills

Audits

Staff supervision

Medical coding audits

SOX controls

Education

Bachelor’s degree in Healthcare Administration

Bachelor’s degree in Business Administration

Job description

GENERAL DESCRIPTION: Responsible for guaranteeing that the internal and external audits of Independent Contractors and Providers scheduled in the unit’s program are executed within the established period. Monitors the execution of the work plan for clinical coding audits, and the quality of the processes carried out in the different operational areas of the company that may represent a risk in case of a Risk Adjustment audit conducted by CMS. Identifies them and offers recommendations.

Regular
Exempt
GENERAL DESCRIPTION: Responsible for guaranteeing that the internal and external audits of Independent Contractors and Providers scheduled in the unit’s program are executed within the established period. Monitors the execution of the work plan for clinical coding audits, and the quality of the processes carried out in the different operational areas of the company that may represent a risk in case of a Risk Adjustment audit conducted by CMS. Identifies them and offers recommendations.

ESSENTIAL FUNCTIONS

• Develops and updates annually the work plan of the audits to be performed to the internal coding team and independent contractors hired to perform the diagnosis coding process. Oversees the performance of clinical coding audits in the Premium Management Operational Unit, evaluating the results obtained to design strategies. Recommends to the unit management the necessary strategies to improve and/or correct the identified findings.
• Through written and/or telephone communication, visits and guides Providers, IPAs, and/or Medical Office Billing Representatives, because of audits and/or referrals received about areas of opportunity identified and related to good coding practices, documentation, and validation of diagnoses, among others, carried out in the audits.
• Guarantees compliance with the procedures established for the achievement of the objectives outlined in the unit’s work plan and related processes.
• Guarantees that the record of the different audits performed and the findings identified for the corresponding corrective plans are kept up to date.
• Monitors the result of the implementation of action and/or improvement plans for the needs identified in the audits.
• Prepares and submits reports to the management on the audits carried out, according to the established work plan.
• Monitor all the Premium Management SOX Controls, ensuring that each operational area is complete and maintains the corresponding evidence. Comply with all requests made by the Internal Audit Department promptly.
• Develops and periodically reviews the unit’s policies and procedures with the required operational procedures.
• Support the coding and documentation guidelines periodical revision, performed by the Operations Management team.
• Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

Minimum Qualifications

Education and Experience: Bachelor’s degree in Healthcare Administration, Business Administration, or health-related fields. At least five (5) years of experience in a similar position performing audits in diagnosis coding, medical records review, clinical information extraction, medical terminology, identification of risks in operational areas, and staff supervision. Which includes two (2) years of experience supervising personnel.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: A valid Certification in Medical Billing, or a Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) is preferred.

Other: Knowledge of legal aspects of medical records. Available to travel around the Island, Vieques, and Culebra; work extended hours, holidays, and weekends. Must have a car in good condition and a driver’s license valid in the Commonwealth of Puerto Rico.

Languages: Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
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