QR Auditor – Clinical

JOB DESCRIPTION

Location: Corporate Bakersfield Job Summary:

The Quality Review (QR) Auditor (Clinical) performs initial and ongoing quality audits and education to Omni Family Health (OFH) providers and coders to ensure that billing codes are appropriate lessening the need for rework.  This position also provides education to the medical and coding staff in collaboration with the clinical documentation requirements, specific to coding queries and documentation issues.  Audit and educate medical and coding staff on issues related to the government mandated guidelines and the outpatient prospective payment system (OPPS).  Provide educational assistance via monthly/quarterly reports on correct coding to physicians and non physician providers.

 

Job Duties:

The following are essential job accountabilities:

 

  1. Work with Supervisor to provide summary reports to the CMO.
  2. Ensure quality of department work product by assisting in department(s) review and coding all physician and non-physician provider (NPP) services for appropriate and accurate billing, following Medicare guidelines; and maintaining compliance with federal rules and regulations.
  3. Ensures provider and staff compliance with expected accurate documentation standards by conducting baseline audits for new coders and providers and provide results and conduct follow up visit within 72 hours of audit completion to ensure appropriate and accurate CMS guidelines and Federal regulations are being followed. Responsible for development of action plan to be completed within initial 90 days of employment with OFH when issues are identified.
  4. Expected to provide face-to-face reviews and trainings to OFH staff (including providers and mid-levels) at OFH health center locations.
  5. Regularly monitor coding workflow, productivity and coding quality to respond to increased variances and coding optimization opportunities.
  6. Ensures that work quality for coders and provider by conducting monthly & quarterly audits as identified by baseline results of 85% or below.
  7. Responsible to schedule timeframe for corrections based on audit findings and has the authority to request corporate compliance with documentation expectations.
  8. Assist billing office in auditing and coding of employed physicians and mid-level providers within OFH.
  9. Supports compliance by assisting in the education of accurate and timely documentation practices and of coding medical services in compliance with CMS guidelines and Federal Rules & Regulations.
  10. Works with OFH billing office leadership to monitor denials specific to coding deficiencies, develop and implement innovative methods to decrease denials that directly impact reimbursement for services rendered.
  11. Assist in researching coding and billing issues, and analysis of data for reports.
  12. Various other work-related duties as assigned by supervisor. These duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally either verbally or in writing.

 

Additional Duties

  1. HIPAA compliance – Responsible for enforcing compliance with all HIPAA regulations and requirements. Treats all member information confidential.
  2. Compliance – Ensure compliance with all local, state, and federal regulations.
  3. QA/QI – Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
  4. IT – Required to learn and use the Electronic Health Record and Practice Electronic System and its components as required by the job functions and highlighted in the Policies and Procedures.
  5. All employees will participate in Patient Centered Home Health Model at Omni Family Health.

 

Job Requirements

  1. Ability to work under pressure.
  2. Ability to demonstrate effective communication skills with providers and management staff.
  3. Ability to develop teaching and auditing tools to provide educational programs for physicians and billing staff.
  4. Proficient with excel and other Microsoft office products.
  5. Knowledge of 3M encoder and/or encoder pro software.
  6. Maintain annual coding certification requirements.
  7. Must have a working knowledge of coding rules, and third party payer requirements.
  8. Must have reliable transportation.

 

Qualifications, Education, and Experience

Education:

  • High school diploma or GED

 

Experience:
  •    Minimum of two years billing and accounts receivable experience in a physician practice environment.
  • Minimum of three years physician coding experience in a multi-specialty environment.

Certification:

  • CPC, CPCH, and/or CCS-P certification required

 

Responsible to:           Director of Billing

Classification              Full-time, Non-exempt