The auditor provides quality assurance of various aspects of risk adjustment and quality related work. S/he is responsible for performing monthly audits on both quality and risk staff and assisting with carrier audits. S/he will audit a 5-chart sample from each staff member on a monthly basis. S/he will provide feedback to staff as needed, track staff performance and report findings to department supervisor. S/he will work with Data coordinator to perform carrier audits to ensure proper reimbursement for the company. S/he will audit each carrier yearly for the previous payment years accuracy, in addition to performing monthly carrier checks. S/he will relay audit results and reason to department supervisor. S/he will check system functionality weekly to ensure Quality and Risk Adjustment EMR based functions are working properly.
Essential Duties and Responsibilitiesinclude the following. Other duties may be assigned.
- Maintains active professional certification and complies with all educational, professional and ethical requirements of said certification
- Ensure departments compliance with all coding guidelines and government regulation
- Know all changes in coding guideline
- Provide weekly summary to Quality/Risk Managerof concerns, trends and carrier updates
- Ensure that codes are being submitted based on CMS guidance not carrier guidance
- Work with educator and department supervisor to ensure a 95% accuracy is maintained by staff
- Maintain a high-level knowledge of Quality measures
This job has no supervisory responsibilities.
To perform the job successfully, an individual should demonstrate the following competencies:
Analysis/Problem Assessment Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.
Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.
Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.
Compliance - Employee has satisfactory completed employers required compliance training.
Employee is able to demonstrate an understanding of employers Code of Conduct.
Follow-up - Establishing procedures to monitor the results of delegations, assignments, or projects; taking into consideration the skills, knowledge, and experience of the assigned individual and characteristics of the assignment or project.
Initiative - Making active attempts to influence events to achieve goals; self-starting rather than accepting passively; taking action to achieve goals beyond what is required; being proactive. Practices self-development.
Integrity - Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities.
Judgement/ Problem Solving - Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others.
Patient Service Orientation - Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence.
Results Driven& Execution - Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative. Team work/ Collaboration - Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions.
Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Associate degree and/or equivalent from two-year college or technical school and/or 1 years clinical and/or Medicare Risk Adjustment experience and/or 1 years of quality improvement experience, or other relevant experience preferred.
Experience working in health care and insurance industry.
Knowledge base of clinical standards of care, preventive health standards and Medicare Risk Coding.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
To perform this job successfully, an individual should have proficient knowledge of Microsoft Excel Spreadsheet software; Microsoft Word Processing software, Outlook and ADP Payroll systems. Knowledge of Computers, Fax, Portals, Uploading, Downloading, Athena or other Electronic Medical Record System.
Certificates, Licenses, Registrations
Certified Coder; CPC, CCS-P, CCS-H, RHIT
Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate depending on business activity of the office.0