PRIMARY FUNCTION:

To oversee the daily activities of the Medical Audit Department. Uses knowledge of revenue cycle principles to ensure accurate and compliant billing while playing a key role in the clinical support of the hospital/physician chargemaster.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provides overall management and direction of daily duties related to auditing, pre-bill editing, charging, education, training and compliance controls.
• Monitors efficiency and effectiveness of each function that occurs within the department.
• Identifies, researches, and analyzes billing errors and/or omissions.
• Prepares and revises policies and procedures as warranted, conducts in-service/meetings with caregivers. Monitors caregiver's productivity and performance.
• Safeguards the integrity of billed accounts by ensuring compliance with billing, documentation and coding standards.
• Implements various strategic initiatives measuring the effectiveness and efficiency of on-going procedures and coordinating procedural changes.
• Responds to all inquiries, issues, concerns as related to the Medical Audit Department
• Uses clinical knowledge to evaluate the appropriateness of a service or proposed code.
• Uses clinical and coding knowledge in overseeing chart audits for compliance, accuracy, completeness, and charge capture. Prepares reports and action plans as needed. Consults with fellow managers and staff regarding identification of billing and reimbursement issues.
• Oversees the audits of patient bills against the medical record, determining accuracy, making changes as necessary and providing corrective intervention to reduce further occurrences. Files appeals as needed.
• Oversees insurance defense and concurrent audits by reviewing the patient medical record and the itemized statement, analyzing discrepancies to ensure charges reflect adherence to physician orders, hospital policy, and accuracy of items and services received.
• Provides support as requested to Billing, Admissions, Customer Service and Ancillary Departments, by researching and reviewing third-party payor problems and issues for clarification and equitable resolution of charges and services rendered.
• Assists in the development of annual departmental goals and objectives.
• Attends, participates and conducts departmental staff and management staff meetings.
• Maintains comprehensive knowledge of regulatory requirements related to third party billing rules.
• Complies with the approved budget.
• Adheres to established departmental safety rules and practices and reviews routinely with staff.
• Performs other duties, as required.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Bachelor's Degree
• At least five years of experience in a clinical/coding position with leadership responsibilities