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Job Summary:

The Clinical Compliance Auditor is responsible for the management of denials/appeals received from third party payers, and government entities/auditors related to clinical validation reviews. The Clinical Compliance Auditor is responsible for reviewing medical records to determine whether the documentation substantiates the medical necessity, utilization, billing and coding of claims. Audit hospital medical records to ensure compliance with coding, documentation and regulatory standards. Reviews the medical record for relevant clinical data to develop and draft clear, succinct appeals to support the claim submitted within the timeframes of appeal based on the payer. Conduct medical record reviews to ensure accurate documentation, coding, charging and billing practices. Establish effective communication and provide education to coding staff, physicians, clinical staff, and/or hospital staff to address documentation, coding, and reimbursement issues. Use knowledge of compliance guidelines to identify potential billing / reimbursement issues. Ability to work remotely and independently with self-driven focus on job completion. Create educational material as needs are identified based on audit results. Research applicable governmental regulations and CMS guidance etc. as needed to conduct audits and/or provide guidance to department and operational leaders. Keep abreast of CMS guidelines and the latest updates. Perform other duties as assigned.

Core Responsibilities and Essential Functions:

Audit Medical Records and Review Claim Denials - Investigate and audit medical records for appropriate coding, billing, patient status, clinical indicators and supporting documentation. - Review and appeal as appropriate commercial payer clinical validation denials. - Review and appeal as appropriate governmental payer denials. (ex: RAC, MAC, OIG etc.) Benchmark comparisons and identification of trends and errors in coded data - Review data analytics for identification of denial trends - Identify / track trends and errors to identify overpayments or revenue enhancement opportunities; - Trend and analyze denials, provide feedback and education to all key stakeholders - Distribution and analysis of reports to relevant, affected departments and stakeholders Provide education and support - Review CMS regulations and official coding guidance to stay abreast of compliance/coding/billing regulatory changes and directives. - Provide denial/appeal follow-up to key stakeholders - Provide education/feedback on new directives from Medicare and Medicaid to key stakeholders

Required Minimum Education:

Graduate from an accredited School of Nursing. Required

Required Minimum License(s) and Certification(s):

Reg Nurse (Single State) 1.00 Required RN - Multi-state Compact 1.00 Required

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 5 years healthcare experience Required and Minimum 1 year experience working with clinical validation denials/appeals and/or clinical validation auditing. Required

Required Minimum Skills:

Ability to use Microsoft products, EXCEL, Word and have basic computer operational knowledge.

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