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Charge Defense Auditor in Emeryville, CA at Integrated Resources, Inc

Date Posted: 10/24/2018

Job Snapshot

Job Description

JOB SUMMARY
 
This position fulfills 3 distinct roles:
 
I. Defense Auditor:  This position is responsible for the administration of the UCSF Medical Center  policy regarding  third party claim audits. These audits are conducted by external auditors representing commercial insurance payers. The external auditors review charges and Medical Records to determine whether the charges submitted and billed to the payer are warranted and supported by Medical Record documentation. The Defense Auditor role is to review and analyze the same disputed charges and documentation and provide sufficient information to overturn or dispute the external auditor’s findings and therefore minimize the potential financial impact to reimbursement. Duties include ensuring that the conditions for allowing external audit comply with the contracted rules for each payer. Documentation and supporting APEX information are gathered and reviewed prior to a third party auditor entering the building for the on- site review. Defense auditor ensures that all appropriate fees are paid, audit outcomes and results are communicated in a timely fashion and any associated education resulting from an audit is provided timely. Defense auditor informs other units with PFS of audit results for potential rebilling , refunds or charge corrections. 40%
II. Acts as the Unit Lead for the Non-Government Billing and Data Control unit. This unit comprises 3 Administrative Assistants and 1 Senior Collection Representative and 1 Analyst . This lead position supports the unit supervisor in the non-Government billing and Data Control functions units. In supervisors absence the lead establishes work priorities and assists with unresolved billing questions and billing issues.  Additionally, acts as the lead coordinator for various Cosmetic packages where charge review, reimbursement review, charge transfer and payment posting is required. 30%
III. Responsible for APEX  Simple Visit WQ’s. Monitoring and updating resolution through analysis and potential outside department coordination related to DNB edits preventing claim generation. This includes reviewing Medical Records and resolving Diagnosis, Charge and Charge provider and updating APEX accordingly. 30%
 
 II.   Report to: System Support/Operations Manager
 
III.  Frequent Contacts:
Frequent contact with Patient Financial Services staff and management, MGBS staff and management. Also includs various outside vendors, auditors and UCSF’s commercial insurance payers.
Outside contacts include: Case Management; Pharmacy; Clinical Laboratory; Operating Room; Emergency Room; OHNS; and Pediatric departments.
 
 QUALIFICATIONS
 
REQUIRED
 
  • High school graduation, BS preferred. 
  • Ability to work with clinicians, ancillary staff and revenue cycle staff to identify critical reimbursement issues and resolve them in an expedient manner.
  • Knowledge of charge system, charge master structure, documentation and coding procedures.
  • Excellent analytical and organizational skills.
  • Excellent interpersonal, verbal and written skills.
  • Current Procedure Coding certification.
  • In depth knowledge of ICD10, CPT4, HCPC, DRG, ASC, UB Revenue Codes and familiarity with UB04 and 837I billing regulations and requirements.
  • Understanding of HIPAA rules and regulations.   
 
 
Duties & Essential Job Functions
 
  • Review audit requests to ensure compliance with ‘Conditions for Audit’ section of hospital policy.
  • Schedules audits with outside auditing firms, and determine focus of audit review.
  • Provide in-depth review and analysis of charges, services and documentation to  support “defense” of charges.
 
  • Coordinate procurement of itemized bills and medical record/charge support documentation.
  • Support and defend hospital charges where appropriate, using clinical knowledge, appropriate regulatory support, Medical Record and other documentation.
  • Meet with the external auditor in an exit interview and mutually agree on a timeframe for issue resolution.
  • Make a determination of “agreement “ or “non-agreement” with external audit findings and determine next steps. This may include charge reversals, rebilling, claim corrections and possibly refunds to the third party    .
  • Review audit outcomes with supervisor and Assistant Director before final sign off of audit results..
  • Provide education to ancillary managers and physicians as needed.
 
 Additional Duties
 
  • Managing DNB and late charge work queues (WQ 9 and 99, respectively).15%
  • Completes simple coding categories (Attending Physician is Missing, Invalid Attending Provider, and Primary Diagnosis Missing) on WQ 934. 15%
  • Assists with maintaining the Timely Filing category on the daily Hold Report.10%
  • Completes custom billing for cosmetic combination packages.10%
  • Records billing statuses for HAC cases. 5%
  • Assists with inpatient billing in the absence of the inpatient biller.5 %