Auditor Clinical Validation OPSP Clinical

Overview

This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting, and services delivered.

Responsibilities

Audits Outpatient and Specialty Claims:

• Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims.
• Draws on advanced coding expertise and industry knowledge to substantiate conclusions.
• Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues.

Effectively Utilizes Audit Tools:

• Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties.
• Enters claim into Cotiviti system accurately and in accordance with standard procedures.
• Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept.

Meets or Exceeds Standards/Guidelines for Quality:

• Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.

Identifies New Claim Types:

• Identifies potential claims outside of the concept where additional recoveries may be available.
• Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.

Recommends New Concepts and Processes:

• Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience.
• Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction.
• Evaluates information and draws logical conclusions.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

Qualifications

Education (required):

• Associate or bachelor’s degree in nursing (active /unrestricted license) AND Certifications/Licenses (required).
• Coding Certification required and maintained i.e. CPC, …