Under general supervision, using a unique combination of clinical expertise and billing knowledge, the Senior Clinical Documentation Auditor/Educator monitors and improves the quality of clinical and financial documentation related to the provision of patient services. The Senior Clinical Documentation Auditor/Educator coordinates, finalizes, and defends patient account audits, reviews documentation for lost charges, has demonstrated ability to write compelling and successful appeal letters. The auditor will compare clinical and financial records to ensure that the documentation provided supports the patient charges listed.
- Performs audits of clinical documentation, physician billing and payment records and applicable industry standard billing codes by analyzing medical records, coding records and health system bills validating clinical documentation in conjunction with the bill; assessing the level and accuracy of coding, determining that governmental and third party payer regulations are being complied with; and evaluating appropriateness of billing and coding procedures.
- Evaluates accuracy of coding and billing performance by individuals and clinical units.
- Prepares reports and providing individual and/or group education to physicians and others based on results of audit.
- Works collaboratively with appropriate personnel to identify and recommend strategies for process improvement and to develop and draft billing and coding policies in coordination with appropriate stakeholders.
- Coordinates responses to and analyzing risk associated with audit requests from government and commercial payers.
- Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
- Develop and conduct clinical documentation audit project plans.
- Develop and maintain complex audit processes and audit tools.
- Audit established guidelines for medical necessity, clinical trials billing, and other specialty clinical services provided in acute care and ambulatory settings.
- Analyze training needs and identify, select, or develop appropriate training programs including training aids and materials to address audit findings and other remediation requirements.
- Train administrative and support staff in the use of audit tools and databases.
- Identify patterns or trends that require auditing, additional training, and/or corrective action.
- Research, analyze, and recommend internal/external policies or responses to regulatory changes or requirements.
- Recommend and assist with revisions to Policy and Procedure and/or work process development.
- Participate in Advisory committees and/or compliance-related Councils.
- Participate in compliance-related investigations and remediation efforts.
- Assists the Chief Compliance Officer in ensuring that Jefferson Health's Compliance Program fully meets the standards for effective health care compliance programs as established by federal regulators.
Bachelor’s degree in Health Information Management or related field
CERTIFICATES, LICENSES, AND REGISTRATION:
One or more of the following certifications required: CPC (Certified Procedural Coder), CCS-P (Certified Coding Specialist - Physician) RHIA (Registered Health Information Management Administrator), RHIT (Registered Health Information Management Technician)
Minimum of five (5) years of progressive experience in coding, reimbursement and regulatory compliance audits either through employment, consulting or other appropriate capacity is required