The Code-Based Reimbursement Auditor performs audits of Charge Master driven and HIM assigned codes and medical record documentation against the itemized charges and facility assigned on government and non-government accounts and adjusts them for incorrect items and/or services; Assists with billing edit resolution and provides coverage guildelines for billable services. Relies on education, some experience and judgment to accomplish job and works under general supervision. Creativity and some latitude is expected to complete responsibilities of the role.

Responsibilities

Regulatory Compliance & Education
1. Daily and/or weekly websites are reviewed to include the Federal Register, Medicare and Fiscal Intermediary transmittals, bulletins, and memorandums, including NCD, LCD/LMRP, OCE, and CCI edit management, payment reconciliation, and financial impact analysis.
2. Written communication of current and pending APC and other government program regulations is provided to designated hospital team members.
3. Bi-yearly training sessions to designated hospital staff and provides education to revenue producing department managers/directors and ancillary department staff is provided on as needed basis.
4. All CMS, Medicare and Medicaid bulletins are reviewed and internal changes are made as needed to keep the facility coding and charge practices compliant with applicable rules and regulations and provides updates to affected departments.
Process Improvement
1. Monthly observations and recommendations are made to prevent future billing problems. Develops process improvement initiatives from which government program-related problems can be resolved.
2. Bill rejections and payment delays due to coding and billing practices as evidenced by CCI edit and LMRP are decreased, increased timeliness and accuracy of federal and state reimbursement, and any other reporting metrics that provide benchmarks to improvements.
3. Reports are prepared as required by management regarding process improvement recommendations and systemic claim processing issues.
Focused Medical Audit & Analysis
1. Medical record audits are performed to ensure all services provided are accurately reflected on the itemized statement and all related documents, i.e., UB92.
2. Focused retrospective claims/records are reviewed for accuracy. Effectively defends facility charging and coding practices during focused audits.
3. Coding and billing problems are identified as they pertain to APCs Reviews claims to ensure correct CPT-4, and HCPCS Level II codes for outpatient accounts.
4. Data is developed and analysis is created regarding effects on revenues due to requested or mandated changes to the CDM and/or billing practices.
Other Duties as Assigned
1. Other duties as assigned

Qualifications

3 years experience
Associate Degree in Nursing or HIM
Proficient in payment review systems, payment methodologies and insurance terms. Ability to synthesize and evaluate data. In-depth knowledge of ICD-9-CM, HCPCS, CPT-4 nomenclature, codes and guidelines and 3M coding software.
Current RHIT or LPN License

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