Lead Health Information Management Audit Specialist

• Prepare & report the status & outcome of the various components of the Audit & Compliance section of HIM

• Serves as a central communication audit resource to support requirements and proper follow-up.

• Assists with overseeing adherence to standards for conducting audits and reviews for the HIM Department and BILH to ensure appropriate release of information in accordance with law and contractual obligations.

• Works closely with the Director of HIM as needed and HIM Audit Manager to support new, regulatory compliance issues.

• Assists in the assignment of tasks and helps resolve technical & operational problems and provides direction and teamwork.

• Leads and assists with all audits for CMS, CERT, RACs, ADR, Quality, Medical Necessity, DRG Insurers submissions, etc. Researches cases, transfers documentation to electronic media, updates the intra-departmental database, communicates issues and findings to the Director of Internal Audit/Compliance, Director of Case Management, and Coding Manager as appropriate. Coordinates and follows entire audit appeals and supports reporting for tracking, financial, and risks.

• Coordinates BILH audits by leveraging Cobius Health for audit tracking and supports various workflows. Reviews billing/claims data in Epic.

• Researches and analyzes CMS requirements for billing in preventing revenue recoupment advising Director of Internal Audit and compliance re non-compliant Physician Evaluation and Management coding/documentation.

• System administrator for Audit tracking system. Follows up and tracks the entire audit appeal process by monitoring report claims data for financial risks utilizing the audit management system. Prepares graphs/PowerPoint slides for reporting at various venues.

• Trains external and internal auditors in the navigation of a variety of systems necessary for the completion of audits, including Epic, BILH systems ECMS/Documentum. Possesses strong analytical/problem-solving software skills.

• Works with Physicians, Billing, and Administrative personnel throughout BILH to formulate appeals to assure that BILH receives appropriate reimbursement or to correct documentation/billing practices to ensure compliance with Federal law and plan requirements.

• Provides documentation to the Referral Office to ensure proper billing and reimbursement of requested procedures/testing.

• Responds appropriately to miscellaneous requests from third-party payors and the Patient Financial Services department, in order to achieve proper reimbursement, satisfy contractual obligations and assure compliance with regulations. Demonstrates competency and critical thinking in evaluating and prioritizing auditor requests. Can accurately explain to auditors the requirements and remedies necessary for incomplete requests. Escalates as appropriate to manager.

• Keeps knowledge base current regarding new coding, compliance, and other regulatory issues.

• Coordinates other audits/projects as assigned by the Manager or assists in the completion of audits.

Minimum Qualifications:

Education: Clinical background (RN or LPN) and/or HIM degree/Coding certification is strongly preferred, but equivalent working experience may be substituted.

Experience: 3-5 years of healthcare experience is required.

Skills, Knowledge & Abilities:

• Required knowledge of the following: medical terminology, anatomy and physiology, and general coding guidelines for Reimbursement and healthcare processes.

• Experience using EHR system, Microsoft Word and Excel.

• Excellent oral and written communication skills are required.

• Demonstrate the ability to manage multiple projects simultaneously and independently is required