When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Under direction from the Manger of HIM Audit and Research, is responsible for a variety of third party audits of medical record data for reimbursement, regulatory compliance, quality and appropriateness. Assists in the medical record documentation review for JCAHO compliance, editing of data required by the State Division of Health Care Financing and Policy and other projects/initiatives as necessary.
Job Description:
Essential Duties & Responsibilities including but are not limited to:
1. Audit Functions
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Assists the manager of audit in planning and evaluating procedures that support the overall goals and objectives of the HIM Department.
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Prepare & report the status & outcome of the various components of the Audit & Compliance section of HIM
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Serves as a central resource in order to decipher medical conditions, disease processes and terminology.
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Develops & assists w/overseeing adherence to standards for conducting audits and reviews for the HIM Department.
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Works closely with the Director of hospital compliance to support new billing related and audit regulations, regulatory compliance issues confronting the industry & changes in management protocols affecting compliance.
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Assists in the assignment of tasks and helps resolve technical & operational problems.
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Assists in evaluating the impact of solutions to ensure goals are achieved in the audit area as well as the HIM Department as a whole.
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Assists in providing effective direction, effective teamwork & motivation efforts and fosters integration of efforts with system-wide initiatives.
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Coordinates CMS Probe audits. Researches/analyzes CMS requirement for billing. Advises Director of Internal Audit and compliance re non-compliant Physician Evaluation and Management coding/documentation.
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Submits/analyzes data necessary for the Federal CERT (Comprehensive Error Rate Testing) program. Researches and refers issues to Manager and the Director of Internal Audit and Compliance.
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Runs/creates reports from the 3M abstracting system for a variety of users, including the New England Organ Bank, and for verification of data for submission to the State Division of Health Care Finance and Policy.
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Coordinates physician re-credentialing audits as required by Managed Care providers, including provision of appropriate documentation to the auditor and discussion/education of the auditor in Lahey’s practices. Communicates with the Managed Care Office re issues/requests.
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Trains external and internal auditors in the navigation of a variety of systems necessary for completion of audits, including ECMS/Documentum, LCMC and Dictaphone EXText.
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Responds to request from the Medicare ADR (Advance Developmental Request) program. Assures location and submission of appropriate documentation within timeframe specified by requestor. Researchers problems and refers them to the appropriate area.
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Coordinates annual HEDIS (Health Plan Employer Data and Information Set) audits as mandated by Managed Care Plans. Provides appropriate information to assure that the quality of care at Lahey is appropriately represented in the final results.
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Leads or assists in the performance of audits/projects to assure compliance with JCAHO requirements, Department of Public Health regulations and HRO standards.
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Is directly responsible for the BC/BS Charge audit. Coordinates retrieval of records/on-line documentation. Accesses and reviews on-line Billing information. Discusses issues with the auditor and resolves if appropriate. Works with Physicians and Administrative personnel throughout the Clinic to formulate appeals to assure that Lahey receives appropriate reimbursement or to correct incorrect documentation/billing practices to assure compliance with Federal law and plan requirements.
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Is directly responsible for the BC/BS DRG audits. Coordinates appeals with the Coding Manager and Physician advisor.
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Leads or assists in the performance of audits required by the Office of the Inspector General, Medicare, Federal Oversight Agencies and the Internal Audit department. Educates senior administrative and legal staff of documentation/Coding requirements and clinical issues as necessary.
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Provides documentation to the Referral Office to assure proper payment of requested procedures/testing.
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Responds appropriately to miscellaneous requests from third party payors and the Patient Financial Services department, in order to achieve proper reimbursement, satisfy contractual obligations and assure compliance with regulations.
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May assist in the editing of data required by the State Division of Health Care Finance and Policy.
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Coordinates other audits/projects as assigned by the Manager, or assists Manager in the completion of audits.
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Interacts with H.I.M. managers, supervisors and section leaders to resolve record retrieval issues and other problems. Interacts with Physicians, Nurses, Administration, Patient Financial Services staff and third party payor personnel regarding reimbursement and documentation issues.
2. Judgment Initiatives
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Covers all functions in the manager's absence.
Minimum Qualifications:
Education: Clinical background (RN or LPN) and/or HIM degree/Coding certification strongly preferred, but equivalent working experience may be substituted.
Licensure, Certification, Registration: see above.
Skills, Knowledge & Abilities:
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Knowledge of medical terminology, anatomy and physiology required.
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Knowledge of ICD-9-CM Coding, CPT Coding and DRG payment methodologies helpful.
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Knowledge of reimbursement policies and healthcare processes required.
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Experience using Microsoft Word and Excel preferred.
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Excellent oral and written communication skills required.
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Demonstrated ability to handle multiple projects simultaneously and independently required.
Experience:
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Five years of healthcare experience required.
Pay Range:
$20.00 – $26.92
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.
