Pro Fee Auditor, Educator

This is a fully remote position, open to applicants in New Mexico.

📋 Description

• Provides direct support to the Coding and Documentation Quality Assurance (CDQA) team by ensuring the implementation and adherence to organization-wide and departmental coding policies and procedures for PHS.

• Ensures compliance with all external regulatory agency coding guidelines and standards.

• Exhibits a high level of expertise in conducting and/or overseeing on-site internal audits or assessments to evaluate compliance and quality monitoring executed by PHS/PMG departments.

• Acts as a resource for queries related to documentation, coding, billing, and coding compliance.

• Engages in special projects associated with coding compliance, creates and presents educational programs, shares information with PHS/PMG departments, and develops educational tools to uphold compliance with regulations.

• Offers support through auditing and training on enterprise-wide corrective action plans for coding, audit, and personnel identified as low performers among physicians and clinicians.

• Conducts reviews of medical records and billing for denied and appealed claims, taking necessary actions to ensure correct claim payments.

• Manages the review and tracking of appealed claims, including facilitating communication with relevant payers.

• Investigates and interprets regulations from all regulatory agencies.

• Serves as a liaison to the Manager of Information Services, Finance/Patient Financial Services, all hospitals, PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance, and all ancillary departments to resolve coding, auditing, compliance, and training challenges.

• Collaborates with all levels of management to ensure accurate, complete, and timely documentation in both electronic and hard copy formats.

• Maintains and shares current technical knowledge of legal and regulatory information from relevant jurisdictions pertaining to the business area.

• Investigates coding, billing, and charging compliance concerns, suggesting and implementing corrective action plans to ensure compliance with regulatory agencies when necessary.

• Identifies risks, formulates and follows up on action plans, pinpoints lost revenue opportunities, and addresses overpayments due to coding and/or documentation errors while providing compliance education.

• Aids in creating the CDQA Annual Audit Work-plan by leveraging the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, along with internal and external risk assessments.

• Regularly exercises independent judgment to assess the reliability of reviewed data; suggests modifications in existing practices to achieve or sustain compliant behavior.

• Stays actively updated on the healthcare industry’s business climate.

• Responds daily to inquiries and requests regarding coding and auditing challenges, as well as conducting ad-hoc analyses for all PHS management.

⛳️ Requirements

• High school diploma or GED is required.

• Must hold at least one of the following licenses/certifications: RHIT, RHIA, CPC, CCS.

• A minimum of three (3) years of experience in coding and/or auditing is required.

• Audit experience is preferred.

• Excellent written and verbal communication skills are essential.

• Strong attention to detail and results-oriented mindset.

• Ability to work independently and make autonomous decisions.

• Knowledge of medical terminology, ICD-9, CPT-4, and HCPCS is required.

• Must possess a thorough understanding of Medicare, Medicaid, and other third-party payer documentation, coding, and billing regulations for assigned service lines.

• Strong organizational and planning skills are necessary, including the ability to prioritize multiple tasks and execute them accurately and simultaneously.

• Proficient computer skills are required, particularly with Microsoft Word, PowerPoint, and Excel.

• Must be adept at using the internet and other resource applications for research purposes and to provide documentation supporting regulations cited in audits.

• Strong written and verbal communication skills are essential for effective communication with management at all levels.

• Must embody the characteristics of a highly qualified professional, marked by honesty, integrity, and the ability to inspire and motivate others.

🏝️ Benefits

• Medical

• Dental

• Vision

• Short-term and long-term disability

• Group term life insurance

• Other optional voluntary benefits

• Wellness program offering rewards and gift cards for wellness activities