Revenue integrity auditor

Overview Revenue Integrity Auditor Full Time, 80 Per Hour Pay Period, Day Shift Covenant Health Overview: Covenant Health is East Tennessee’s top-performing healthcare network with 10 hospitals and over 85 outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned, not-for-profit healthcare system and the area’s largest employer with over 11,000 employees. Covenant Health is the only healthcare system in East Tennessee to be named six times by Forbes as a Best Employer.

Position Summary

Performs complex level professional internal auditing work and appeals. Work involves leading or conducting process, financial, appeals, and compliance audit projects for Covenant Health entities as they relate to charging, coding, documentation, and billing compliance. Also provides consulting services to the organization’s management and staff and may participate in requested investigations. Maintains all organizational and professional ethical standards. Works independently under limited supervision with significant latitude for initiative and independent judgment. Reports to the Revenue Integrity Manager.

Responsibilities

Identifies and evaluates company risk areas and provides auditing procedures related to documentation and reimbursement to include: documenting client processes and procedures, assessing risks and adequacy of related manual and automated internal controls, developing criteria, and reviewing and analyzing findings. Also provides corporate oversight of any current departmental audit programs. Reviews ADR log, Appeals Database, and Payor websites to identify audit issues and proactively trend data. Reviews and studies all information published by CMS and the OIG via the Federal Register, fraud alerts, OIG advisory opinions, and other publications relative to coding, billing, and reimbursement compliance in order to ensure compliance. Reviews information from Third Party Payors relative to claims charging, coding, and billing in order to ensure compliance. Performs research and analysis of charges, CPT coding, modifiers, and billing processes to ensure compliance with Medicare/Medicaid guidelines and other insurance Payors and to maximize reimbursement. Explains charges and charging procedures to third party insurance companies for defense audits as applicable. Coordinates with appropriate parties the complete/partial payment or repayment of the claims, as described in the Audit Policy, as findings are identified that are either over-payments or underpayments. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to management and audit committee. Documents all audit activities in a designated location; reports statistics and identified problems monthly or more urgently if deemed necessary. Monitors audits performed at the department level in order to ensure that data is appropriate, being maintained, and being disseminated to leadership as indicated. Assists with Payor denials when necessary. Assists with special projects and performs other duties as needed and requested by the Vice President of Patient Account Services and Corporate Manager of Revenue Integrity. Supports, models, and adheres to the desired behaviors of the KBOS Constitution for quality which are: celebrate and reward successes, seek out better ways to do our job, set improvement goals and standards striving to meet or exceed them, participate in forming and being part of work teams when necessary, and do not say "It's not my job.” Works in conjunction with health information management, patient accounting, information systems, and other personnel to assist with implementation of solutions to maintain a proper compliance stance. Under the direction of Revenue Integrity Manager, works with the Manager of Revenue Processes to assist with implementation of solutions to maintain a proper compliance stance. Under the direction of Revenue Integrity Manager, works with the Chief Compliance Office relative to coding, billing, and reimbursement compliance issues. Under the direction of Revenue Integrity Manager, works with the Chief Compliance Officer in the development and ongoing activities involved in the baseline and periodic compliance audits and compliance programs as deemed appropriate by manager. Works with contract management personnel in the review of contracts and other reimbursement or payment arrangements in relation to charging, coding, and billing compliance. Works closely with Financial Analysts to identify process improvement activities and audit opportunities. Works closely with co-workers to identify process improvement activities and audit opportunities. Advises, educates, and acts as clinical/billing liaison between CFOs, department managers, and billing staff to maximize reimbursement within compliance guidelines for Medicare/Medicaid and other insurance Payors as deemed appropriate by manager in relation to audit findings and process improvement initiatives. Coordinates and facilitates problem resolution sessions where multiple departments and/or service areas are involved as deemed appropriate by manager. Supports, models, and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are: take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service, and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, and keep commitments. Maintains lines of communications with facilities in an ongoing effort to improve the overall quality of customer service. Promotes good public relations for the department and the Finance Division. Motivates coworkers and promotes a team effort in accomplishing goals and deadlines with accuracy, dependability, and professionalism. Supports, models, and adheres to desired behaviors of the KBOS Constitution for caring which are: build a trusting environment by listening with an open mind and valuing different opinions, ask questions for understanding and allow others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work, and respect differences by listening with an open mind. Maintains professional growth and development through continuing education, seminars, and applicable professional affiliations to keep informed of industry trends. Recognizes situations, which necessitate supervision and guidance, seeking and obtaining appropriate resources. Coordinates with staff to ensure necessary materials, equipment, and/or supplies are maintained utilizing all avenues of resource management in ordering supplies for departmental needs. Utilizes resources available appropriately, i.e., use of Covenant Health equipment and/or supplies. Does not promote or participate in solicitation during working hours within the department. Supports, models, and adheres to the desired behaviors of the KBOS Constitution for using the community’s resources wisely which are: be aware of cost and quality when making spending decisions, demonstrate a personal commitment to reduce waste, consider the impact on other departments and facilities within Covenant Health when making decisions or taking action, and ensure that meetings lead to solutions. Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested. Performs other duties as assigned.

Qualifications

Minimum Education: None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority. Minimum Experience: Three (3) to five (5) years of experience in healthcare. Good working knowledge of healthcare billing, Medicare/Medicaid billing guidelines, and other Third Party Payor rules and regulations. Experience in problem solving and analytical reviews. Must be knowledgeable in use of PCs, Windows, Excel, and Word Processing. Must have good public relations skills. Licensure Requirement: Current clinical license/registration in the State of Tennessee or certification in field of healthcare related study, RHIT/RHIA/CPC or clinician with background in provider reimbursement, coding, or utilization management preferred. Candidates who do not meet the licensure requirements as listed above may qualify with an equivalent combination of college coursework and full time work experience. Alternatively, a minimum of ten (10) years of increasing responsibilities in related field equivalent work experience will be considered.