Company :

Job Description : 

GENERAL OVERVIEW:

Senior auditor responsible for clinical or physician compliance topics. Assigned the most complex clinical/documentation/coding/billing reviews. Provides guidance to other auditors within AHN on audit approach and analysis. Responsible for creating and overseeing orientation of auditors. Leads all hospital or physician audits/investigations, auditing support and responses related to external audit activity.

ESSENTIAL RESPONSIBILITIES:

• Establishes and implements orientation for all members of the AHN audit compliance team. Evaluates the progress of team members including review of reports and audit activities. Works with senior management responsible for AHN-wide case management/physician programs to develop processes that meet Medicare and 3rd party payor requirements. Provides guidance to staff auditors on audit topics and reports. (20%)
• Conducts educational sessions for hospital/physician staff. (10%)
• Conducts investigations and performs special projects as assigned. (10%)
• Compliance Auditor- Sr. (Clinical Specialty) Only: Audits/oversees the auditing of 340B program and provides guidance to 340B management team. Participates in meetings specific to case management/UR and assists with 340B regulatory requirements and when needed, monitors corrective actions. Analyzes and summarizes PEPPER reports and recommends high risk areas for audit. Conducts audits of Medicare/Medicaid and other third party payor accounts for documentation, medical necessity, coding (non DRG), charging, billing and compliance with state and federal regulations. Prepares accurate and concise written audit reports. Works with auditees on corrective action plans and educate management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, coding requirements. Responds to external audits of the government (facility based) sent to the compliance office and works with operational owners to establish and implement corrective actions when needed. Advises UR/CM in defending payor claims denials for medical necessity, coding, billing and documentation through coordination of and/or participation (when appropriate) in the appeal process (RACS, ZPICs, MICs and OIG audits in particular and other payors as assigned.) (30%)
• Compliance Auditor- Sr. (Physician Specialty) Only:  Analyzes E&M bell curve reports and recommends high risk areas for audit. Manages the database of new providers and assigns for audit/education to team members. Participates in meetings specific to physician coding, billing and documentation and, when needed, monitoring of corrective actions. Performs internal concurrent, prospective, and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding and documentation is compliant with appropriate guidelines and federal and state regulations. Develops audit detail summary spreadsheets and reports to address any coding, documentation, or financial discrepancies. Conducts presentations of final audit findings to department staff, physicians, and appropriate individuals. (30%)

QUALIFICATIONS:

Minimum

• For Compliance Auditor - Sr. (Clinical Specialty): Bachelor's degree in nursing
• For Compliance Auditor - Sr. (Clinical Specialty AND Physician Specialty): Bachelor's degree or equivalent education and related experience
• 7 years in utilization review, case management, hospital/physician coding and documentation audits/reviews
• Experience with medical necessity denials/appeals

Preferred

• For Compliance Auditor - Sr. (Clinical Specialty: Master’s degree)
• For Compliance Auditor - Sr. (Physician Specialty): RHIT, RHIA certification
• Knowledge of a variety of clinical specialty areas, practices and procedures as well as 340B program

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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