Independently performs audit projects at all levels of complexity. Involves preliminary survey and risk assessment activities. Under guidance, designs audit programs to accomplish review objectives.
- Performs independent/focused reviews of various health system operations and other functions to determine compliance with applicable statutes, laws, rules, regulation, and policies. Drafts sampling methodologies and policy. Collects, prepares, and reports on metrics to identify trends and address issues/concerns. Analyzes trends, collaborate with all levels of leadership to formulate action plans for remedial or corrective action. Monitors the progress and completion of said action plans.
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20 |
Conducts testing based on approved audit programs of moderate to high complexity, which may include tests of the financial and operating system processes, to identify internal control weaknesses and audit findings.
- Resource to physicians/coding staff to answer compliance questions related to billing/coding for professional services across medical specialties. Analyzes/evaluates the accuracy and completeness of place/date of service documentation in the medical record and CPT/ ICD-10 coding by providers in support of claims submitted to government/federal/state, and other third party payers. Validates payments received for professional services rendered are accurate/consistent with fee schedules.
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20 |
Develops formal written reports to communicate audit results to campus management, and makes recommendations as appropriate.
- Communicates audit and findings to the department, physicians, billing managers, and coders.
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10 |
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May participate in investigations and assist with evaluation of allegations, including improper government acts. Follows up on management corrective actions to ensure completion.
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5 |
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May be responsible for external audit liaison duties: coordinates external agency information requests and site visits; analyzes documentation to identify potential risk areas.
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5 |
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Education and Training:
Provides regular compliance training on coding and reimbursement matters and as necessary training based on the findings of compliance reviews. Conduct routine and focused educational programs in compliant coding and regulation updates.
Develops educational materials, and presents educational information to the provider(s), coding groups and assists other areas in staff training to enhance proficient coding and documentation. Provides compliance education and training to physicians, residents, fellows, nurse practitioner, physician assistants and other appropriate personnel for both scheduled and ad hoc requests. Provides direct training in support of continued adherence to policies and procedures for teaching physician billing compliance and associated policies and procedures.
Participates in evaluating and updating of educational and training materials related to billing, coding, and documentation practices and other compliance obligations as needed.
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30 |
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Administrative and Meetings: Independently prepares and edits materials for various projects, including electronic presentations, reports, correspondence and data collection. Maintains a current, organized and detailed audit file system. Responds to incoming phone calls from coders, billers, and physicians and others in a timely manner. Participates and provide regular reports in various committees.
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5 |
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Physician coding: Abstracts information from various chart documentation, dictated reports, electronic health records, encounter forms, hand-written progress notes and various other venues with the use of audit tools to reach appropriate CPT/ASA procedure codes, E/M (Evaluation & Management) codes and all other appropriate billing codes in compliance with University policies and government billing policies. Takes appropriate action if documentation does not support codes. Analyzes and evaluates findings, diagnosis & procedure codes identified by physicians. Reports inconsistencies and/or incomplete charts, to inform the department and/or provider to improve billing/coding practices. Uses sound coding judgment to establish priority sequencing of diagnosis codes & services for maximum allowable reimbursement, consistent with but not limited to University compliance regulations, CMS Medicare & Medi-Cal, HMO, commercial insurance carriers and other related entities; confirms that all codes/modifiers are appropriate. Interacts with internal and external resources to facilitate all aspects of medical coding.
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5 |
