QR Auditor – Clinical


Location: Corporate Bakersfield
    Job Summary: The QR Auditor (Clinical) performs initial and ongoing quality audits and education to OMNI providers and coders to ensure that billing codes are appropriate lessening the need for rework. This position provides education to the medical and coding staff in collaboration with the clinical documentation requirements, as it pertains 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. Work with Supervisor to provide summary reports to the CMO and the Director of Corporate Compliance Physicians. Assist department(s) in reviewing 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.
      Job Duties:
      1. Conduct baseline audits for new coders and providers and develop action plan to be completed within initial 90 days of employment with OMNI. 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.
      2. Conduct monthly & quarterly audits as identified by baseline results (85% or below), scheduled timeframe, or request by corporate compliance. Regularly monitor coding workflow, productivity and coding quality to respond to increased variances and coding optimization opportunities.
      3. Assist business office in auditing and coding of employed physicians and mid-level providers within OMNI, assisting in the education of good documentation practices; and of coding medical services that are appropriate and accurate, maintaining compliance with CMS guidelines and Federal Rules & Regulations.
      4. Works with OMNI business office leadership to monitor denials specific to coding deficiencies, develop and implement innovative methods to decrease denials that directly impact reimbursement for services rendered.
      5. Assist in researching coding and billing issues, and analysis of data for reports.
      6. Performs other related duties as assigned or requested.
      Additional Duties:
      1. HIPAA compliance - Responsible for maintaining abreast of and in 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. These components include NextGen, PMS, QSI and other electronic features, as they are developed and implemented, as applicable to work environment.
      5. All employees will participate in Patient Centered Health Home Model at Omni Family Health.
      Qualifications, Education, and Experience:
      1. High school diploma or GED.
      2. CPC, CPCH, and/or CCS-P certification required.
      3. Minimum of two years billing and accounts receivable experience in a physician practice environment.
      4. Minimum of three years physician coding experience in a multi-specialty environment.
      5. Maintain annual coding certification requirements.
      6. Must have a working knowledge of coding rules, and third party payer requirements.
      Job Requirement:
      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.
      Responsible To: Director of Billing Classification: Full Time Position, Non-Exempt