Working under general supervision, audits complex outpatient, inpatient and professional claim irregularities, overpayments and provider appeals from a clinical coding perspective, applying coding guidelines. Analyzes provider billing for abnormalities, questionable billing practices and proper coding combinations from a clinical and coding perspective and documents denial reasoning or erroneous activity.
This position has the option to work remotely; Ohio residents preferred. Seeking applicants with RN experience, DRG, and/or hospital bill auditing experience.
Responsibilities
Clinical Auditor
- Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.
- Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.
- Maintains knowledge in coding and billing guidelines and trends.
- Reviews provider appeals applying coding guidelines or edits.
- Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with more senior levels to implement changes.
- Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.
- Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.
- Performs other duties as assigned.
Sr Clinical Auditor
- Audits outpatient, inpatient and professional claims from a clinical and coding perspective applying coding guidelines and edits. Assesses for inappropriate billing combinations, inherent charges, provider supporting documentation, etc.
- Documents audit results including denial reasons, erroneous activities, etc. and updates systems accordingly.
- Identifies additional opportunities for recovery and avoidance. Researches opportunities to better control medical spending and presents ideas to management.
- Researches and maintains knowledge in coding and billing guidelines and trends. Participates in implementation of new or updated policies and processes.
- Reviews provider appeals applying coding guidelines or edits.
- Identifies edits to adjudication system that are not working properly or need to be installed so claims can be processed. Works with lead or manager to implement changes.
- Orients, trains, assists and reviews work of more junior level staff.
- Interacts with internal or external auditors or vendors on claim coding updates, procedure changes, etc.
- Discusses consult findings with Physician Reviewers and reviews edit updates and questions with payment recovery staff.
- Performs other duties as assigned.
Qualifications
Clinical Auditor & Sr. Clinical Auditor
Education and Experience
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s Degree preferred.
- In lieu of RN, Bachelor of Science in medical related field.
- 3+ years as a Clinical Auditor or equivalent combination of clinical and medical auditing experience.
Professional Certification(s)
- Certified Medical Auditor (if not certified required to obtain within 18 months of hire).
- Certified Coder preferred.
Technical Skills and Knowledge
- Knowledge of ICD codes.
- Knowledge of procedure codes.
- Knowledge of Revenue Codes, HCPC Codes and CPT codes.
- Knowledge of industry standard billing rules and regulations for professional claims billing, outpatient claims billing and inpatient claims billing.
- Knowledge of insurance regulations.
- Knowledge of coding and auditing techniques.
- Good written communication skills.
- Intermediate Microsoft Office and claims adjudications systems skills.
