Provider Recovery Auditor responsible for auditing claims overpayments and facilitating recovery opportunities. Supporting the Inland Empire Health Plan in achieving quality program goals.
About the role
- Professional Coding and Billing Auditor providing audit support and guidance in compliance to Care New England. Collaborating with management, providers, and staff for effective compliance programs.
Responsibilities
- Provides audit support and guidance to management, providers, residents, and support staff in free-standing and facility-based practices.
- Conducts assigned compliance audits for risk areas identified through the analysis of internal data and external sources.
- Ensures all coding, billing, and documentation complies with federal and/or state regulations, private payor health care program requirements as well as the Care New England Compliance policies.
- Responsible for auditing and implementing training programs to assist in achieving Care New England's goal of an effective compliance program.
- Assists with new provider on-boarding education.
- Consistently demonstrates a comprehensive, expert-level knowledge of all professional fee coding in accordance with federal and state rules and regulations, CMS, AMA, CPT, ICD-10-CM, and HCPCS Level II procedure and supply codes coding guidelines.
- Effectively reviews/audits medical records with focus on Evaluation and Management services to identify opportunities for clinical documentation improvement and potential coding opportunities to optimize reimbursement.
- Correctly identifies and implements education and training opportunities related to coding for physicians and non-physician providers based on results of chart reviews under the direction of Care New England Medical Group management team.
- Be consistently available as a subject matter expert for coding guidelines, questions, and other issues from Care New England providers and staff.
- Assists physician practices and provider-based departments as a coding subject matter expert when necessary.
- Provides baseline coding education to newly hired physicians and non-physician providers/clinicians on a timely basis.
- Effectively prioritizes workload to complete job responsibilities.
- Displays ability to adjust priorities based upon understanding of policies and procedures.
- Completes job responsibilities by deadlines, according to established schedules or workflow requirements.
- Evaluates areas in need of improvement and provides input in order to improve current methods, services, programs, or technology.
- Meets departmental productivity standards.
- Assesses, analyzes and reviews information before making decisions and solving problems.
- Discusses findings with management on an ongoing basis.
- Uses proper judgment and knowledge of established practices and procedures when addressing problems or issues.
Requirements
- Associate degree in Business Management or Health Care Management or a minimum of 3-5 years experience, with a strong emphasis on evaluation and management documentation, coding, billing, and auditing, preferably for a medium to large physician practice group or health system.
- Multiple specialty coding experiences, including behavioral health preferred.
- Bachelors degree preferred.
- A high-level knowledge of medical terminology, anatomy, and pathophysiology, along with understanding of the proper application of CPT procedure codes, HCPCS Level II procedure and supply codes, and ICD-10-CM diagnosis codes.
- Excellent verbal and written communication skills.
- Proficient knowledge of MS Word, Excel, and PowerPoint required.
Benefits
- Health insurance
- Professional development opportunities
Job title
Job type
Experience level
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Not specified
Degree requirement
Location requirements
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