- Purpose of Job
- The Revenue Integrity Auditor is responsible for coordinating and facilitating clinical review functions for all entities to ensure all appropriate billable charges are captured as documented within the patient record.
- Reviews medical documentation and compares to posted charges to determine whether services charged are supported by the medical record.
- Serves as a liaison between Finance, Charge Services, Health Information Management (HIM) and other departments.
- During the course of a review the Auditor will educate clinical staff and department leaders of missed charges, late charges, or incomplete documentation which doesn't support billed charges.
- May assist in external insurance audits or special projects as needed.
- Job Requirements
- Associates or Bachelors Degree in business, healthcare administration, or related area required.
- Bachelors of Nursing (BSN) preferred.
- Demonstrated knowledge of clinical documentation processes and procedures.
- Minimum 5 years experience working in a hospital setting with significant exposure to orders/charge processes and electronic medical records (EMR).
- Current valid Nebraska Registered Nurse (RN) License, valid compact multistate license to work in Nebraska, or a temporary permit while awaiting licensure required.
- Knowledge of Medicare Severity-Diagnosis Related Group (MS-DRG), All Patient Refined-Diagnosis Related Group (APR-DRGs), Medicare Ambulatory Payment Classification (APC), Enhanced Ambulatory Patient Grouping (EAPG).
- Excellent time management and attention to detail skills.
- Excellent written and oral communication skills.
- Self-starter with ability to work with minimal oversight.
- Ability to effectively work in a team environment.
- Strong independent problem-solving skills using critical thinking, logic and reasoning to assess and resolve problems.
- Excellent computer skills, including proficiency in Microsoft Office Suite.
- Physical Requirements
- Weight Demands
- Light Work - Exerting up to 20 pounds of force.
- Not neccessary for the position (0%):
- Occasionally Performed (1%-33%):
- Distinguish colors
- Frequently Performed (34%-66%):
- Repetitive Motions
- Constantly Performed (67%-100%):
- Not Related:
- Chemical agents (Toxic, Corrosive, Flammable, Latex)
- Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
- Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
- Explosives (pressurized gas)
- Electrical Shock/Static
- Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
- Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
- Mechanical moving parts/vibrations
- Essential Job Functions
- Essential Functions I
Performs pre- and post-payment charge audits to identify potential lost revenue opportunities.
Provides education to clinical staff and department managers for effective charge capture.
Identifies opportunities for missed charges and inappropriate billing patterns in accordance with hospital charging protocols and industry standards.
Develops and maintains an effective working relationship with Charge Services, Clinical coding, clinical staff, and department managers to improve processes.
Performs Charge audits and prepares reports to identify missed revenue opportunities for the corporate compliance program.
Works with clinical departments to ensure audit findings are addressed and assist with best practices for charge/order entry moving forward.
Analyzes root causes for duplicate, missing, late charges, or incorrectly charged services and items and provide education as needed.
Keeps abreast of CMS and other federal regulations concerning charge capture.
Keeps Reimbursement Supervisor informed of audit findings and communicates findings with clinical staff and department management team.
Addresses HIM/Coding staff questions regarding charge issues as needed.
Essential Functions II
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
Other duties as assigned.
Methodist Health System