• Risk Adjustment Auditor/Educator

    Posted Date 2 days ago(11/16/2018 8:41 AM)
    Requisition ID
    # of Openings
    100 Front Street
    Job Locations
    Job Code
  • Overview



    Reliant Medical Group is seeking a Risk Adjustment Auditor/Educator to join our excited and innovative organization!


    Full Time: 40 hours

    Hours: Flexible 8:00AM - 4:30PM depending on provider meetings

    No nights or weekends


    Responsible for performing Risk Adjustment internal coding audits/Education and billing compliance reviews of various elements of physician billing for the organization.  Works within specified third party payer and federal (CMS) coding/billing regulations.   Develops training and education materials.  Provides training and education to providers, clinical department and Revenue Operations staff. Provides other internal billing-related compliance services to the organization as required. Measures coding trends as compared to national standards.


    Participates in the identification and resolution of areas requiring additional intervention through established Billing and Corporate Compliance work plans.    

    Develops and implements clinic-wide training programs geared towards educating clinical and non-clinical support staff regarding compliance related topics and/or deficiencies identified through billing compliance audits.


    Develops and delivers clinic-wide memorandums/educational materials pertaining to relevant revenue integrity initiatives.


    Performs Hierarchal Condition Coding (HCC) reviews for Medicare Advantage program beneficiaries following established policy/procedure/process.  Identifies trends that result in lost HCC revenue and educates provider constituency as appropriate.


    Assists in the review and update of annual Revenue Integrity & Education work plan and audit schedule.


    Performs formal review of annual CPT/Diagnosis/HCPC changes and prepares educational documents by specialty highlighting significant changes.


    Trains providers, staff and others in small and large group sessions.


    Meets deadlines, productivity targets as defined in the Billing Compliance Work Plan.


    Communicates effectively at all levels in the organization, including clinical and non-clinical support staff, practice managers, physicians, and medical leadership.


    Conducts random and scheduled internal audits of physician billing and medical record documentation to ensure: Correct Coding (CPT, ICD-9, ICD-10, HCPCS, Modifiers), Accurate Data Entry, Accurate Charge Preparation/Processing, Compliance with governmental and third party billing regulations.


    Utilizes Microsoft Excel / Word, to document and report audit results to the appropriate personnel, including physicians/providers and Medical Leadership.


    Works collaboratively with clinical department physicians, mid-level providers and other staff to ensure appropriate and compliant documentation, coding and billing practices.


    Develops and tracks progress of internal audit schedules.


    Serves as an internal compliance resource for Patient Accounts, Clinical departments, and for coding and documentation questions.


    Utilizes the Internet, intranet, internal reference library, available workshops and/or seminars and other sources to stay current with government and local third party payer coding, specialty-specific and reimbursement rules and requirements.

    Measures and reports coding trends as compared to national standards; or claim/documentation reviews.  Documents and reports results to all appropriate parties.


    Monitors and reports productivity and other data as requested by manager.


    Participates in all governmental and third party insurance audits.


    Assists in developing Revenue Integrity and Education Policies and Procedures.


    Complies with health and safety requirements and with regulatory agencies such as DPH, etc.


    Complies with established departmental policies, procedures, and objectives.


    Enhances professional growth and development through educational programs, seminars, etc. 


    Maintains all Professional certifications.


    Attends a variety of meetings, conferences, and seminars as required or directed.


    Performs other similar and related duties as required or directed.


    Regular, reliable and predicable attendance is required.


    BS in Health Related Field, or RN, LPN with experience.  Certified Professional Coder required (CPC, CCS-P, CCS, CPC-A, CPC-H, CRC). Three (3) to five (5) years experience in ICD-9/ICD-10, CPT and HCPCS coding. Experience with RISK ADJUSTMENT auditing physician medical records utilizing Risk Adjustment guidelines. Utilize standard scoring (CMS) methodologies to report findings to providers. Ability to employ clinical reference with the auditing process. Apply CPT and ICD-9/ICD-10 and HCC/Risk Adjustment coding convention to documentation guidelines. Apply CMS and other payer constraints to final code and documentation determination. Demonstrated experience in the application of medical terminology, anatomy and physiology or successful completion of related college course. Demonstrated experience in a physician/professional billing environment. Demonstrated experience with third party payer guidelines. Experience with Microsoft Office Suite (Excel, Word, Power Point) or successful completion of related course. Must show proficiency in current billing software within six (6) months.


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