Job duties include but are not limited to the following:
· A senior level position in the facility audit function.
· Independently performs comprehensive, multi-dimensional audits for facility.
· Inpatient and outpatient claims, both field and in-house for all lines of
· Ensures claims are paid according to the provider’s contract, standard
· Processing procedures, proper coding and/or billing guidelines for assigned
· Supports the unit and overall departmental goals and metrics that contribute
to the company’s financial stability.
· Reduce medical costs through recovery of overpaid claims.
· Identifying/referring root causes for overpayment and underpayment errors
for corrective action in order to prevent or minimize future claims payment
· Manage the end to end process of the audit.
· Accountable for identification, validation, invoicing, collection and dispute
· Provides peer to peer training on audit techniques for the less experience
· Use coding, clinical and contractual knowledge to identify aberrant coding.
· Performs comprehensive field and/or desk medical record review audits to
validate ICD9/10, CPT, HCPC coding accuracy.
· Performs prepayment high dollar reviews using claim billing guidelines
clinical knowledge and provider contract terms.
· Perform special projects as required/requested.
· Bachelor’s degree or equivalent work experience.
· 6+ years with recent experience as a Nurse or Certified Hospital Coder.
· Current Florida RN License and/or Coding Accreditation with AHIMA or
AAPC for hospitals, CCS.
· Experience with ICD-9/10, DRG, CPT/HCPCS coding, medical record
· Proficient knowledge of medical terminology, claim audit procedures,
provider contracts, claims processing procedures and guidelines.
· Proficient in the use of MS Excel, Word.
· Superior oral, written and interpersonal communications skills.
· Ability to travel overnight or longer within Florida as required by assigned
· Valid driver’s license.
Business Specific Criteria (preferred skills):
· Demonstrated experience engaging senior leaders including but not limited
to CFO’s, CEO’s, COO’s, practice administrators, HIM Directors, Managed
Care Directors and general counsel representatives.
· Certified coder at a provider/healthcare facility, preferably with all types of
insurance (HMO, PPO, Traditional, Medicare).
· Working knowledge of COB, Subrogation and Workers’ Comp, claims
adjustment processes and benefit plans.
· Experience in the preparation of high dollar reviews using claims billing
guidelines, clinical knowledge and provider contract terms.