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Revenue Integrity Auditor

The Revenue Integrity Auditor is responsible for pre- and post-payment auditing of medical records and associated clinical documentation to ensure proper charge capture, billing in accordance with standard billing policies and reimbursement principles. This position is responsible for assisting Revenue Cycle Services, Health Information Management (HIM), Coding, Clinical Documentation Improvement (CDI), and other departments with resolution of billing issues and/or denials requiring clinical expertise, participating in external audit requests, and special projects as needed. This position also serves as an audit outcome educator with clinical staff in clinic and department settings.

Essential Functions and Responsibilities include:

• Coordinates, conducts and documents full or partial chart-to-bill audits for: existing services to ensure revenue capture and documentation accuracy, newly implemented hospital services, defense audits requested by payers or outside agencies, cost outlier and high balance accounts prior to billing or post third party vendor review, and other audits as assigned by management.
• Prepares written reports or trending data related to findings and facilitates sign off with leadership.
• Facilitates timely turnaround of audit results.
• Prepares written summaries of departmental audit results, which allow clinical leadership the ability to monitor and manage their revenue capture and documentation processes.
• Keeps Revenue Integrity Supervisor informed on various findings and communications with areas assigned for audit and/or process review.
• Notifies Charge Reconciliation, Charge Description Master (CDM), and Revenue Cycle Education Staff of pertinent audit issues requiring their intervention to remedy or correct.
• Works cooperatively within Revenue Cycle Support, and clinic/department leadership to ensure all charges are available within the Electronic Health Record (EHR) on an as-needed basis and according to department standards.
• Requests appropriate CDM additions, modifications, deletions and reactivations through the NThrive Workflow Tool.
• Develops and maintains a highly effective working relationship with Corporate Compliance, Finance, HIM, Revenue Cycle Services, Transition Support, and various clinic/department staff and their leadership.
• Provides education to clinical staff and clinic/department leadership on the appropriate utilization of charges in the Electronic Health Record (EHR) and suggests documentation improvements where appropriate.
• Identifies inappropriate billing patterns in accordance with hospital charging protocols and industry standards; makes recommendations for improvement of procedures, documentation, and revenue optimization opportunities.
• Works diligently to attain appropriate Revenue Integrity goals.
• Researches and resolves EHR billing, payer, and customer service related issues in a timely and compliant manner: retrieves and validates patient account information and charge-related documentation from multiple information systems and/or from hospital department personnel, researches and resolves charge concerns identified through Charge Capture Audit (CCA) tool, researches and resolves Revenue Guarding Edits that are built to identify accounts with missing charges, validates that charges are on the correct account via EHR Charge Review work queues, resolves National Correct Coding Initiative (NCCI) Edits, Correct Coding Initiative (CCI) Edits, and Medically Unlikely Edits (MUE), recommends and/or applies appropriate modifiers in support of medical services rendered, researches and corrects Room & Bed and Observation Hour issues, ensures patient satisfaction by resolving charge-related issues routed from Customer Service inquiries, resolves charge issues associated with credit balance accounts, and enters account corrections and detailed comments in EHR to ensure a clear line of communication.
• Researches, works proactively with charging departments, and resolves billing and/or charging issues; resolves Do Not Bill (DNB) Errors and Warnings.

Job Requirements include: Medical Technician, LPN or RN, with current state licensure OR certified R.H.I.A., R.H.I.T., CCS, CCS-P, CPC, CPC-H, CCA, OR Associate's degree required; bachelor's degree preferred, experience with Health Information Management (HIM), Facility/Physician Billing, Charge Description Master (CDM), Denials Management, Charge Integrity, Financial Analysis, three years of experience in a hospital or physician setting with extensive Revenue Cycle knowledge, and two years of hospital audit experience with a concentration in High Balance and Cost Outlier and/or facility-based clinic audits.

Knowledge, Skills & Abilities include: extensive knowledge of various coding systems, including but not limited to ICD-10-CM, CPT-4, HCPCS, as well as medical terminology, anatomy and physiology, diagnostic and therapeutic tests, knowledge of DRG and APC classifications and reimbursement methodologies, extensive knowledge of billing processes and payer requirements, extensive knowledge of NCCI and CCI requirements for Medicare and Medicaid patients including MUE edits, ability to implement or facilitate change utilizing change management techniques, excellent oral and written communication skills, excellent customer service and organizational skills, critical thinking and analytical skills, ability to work independently and exercise professional judgment to meet daily operational demands, ability to work as an effective team member, demonstrates team-oriented, professional conduct when resolving issues which cross operational units within Revenue Cycle and/or across Eskenazi Health, possesses Microsoft Excel skills including the ability to create and build new worksheets, import and sort data, and use basic formulas, possesses Microsoft Word skills to summarize audit outcomes and write internal and external correspondence, and familiarity with information systems used at Eskenazi Health, including but not be limited to: EPIC, McKesson, NThrive, OnBase, G3, and Careweb preferred.