Under the direct supervision of the Regulatory Billing Audit Manager, the Senior Regulatory Billing Auditor is responsible for comprehensive medical audit review and analysis of clinical and technical records to support acceptable and compliant charging, billing and documentation practices at the MaineHealth system.
Working independently, the Sr. Regulatory Billing Auditor will understand and follow Maine Health’s systematic auditing process to examine and ensure organizational accuracy within the confines of the Federal and State laws, regulations, policies and procedures. Upon audit completion, the candidate will be expected to provide statistical reports of findings and appropriately analyze these findings in the form of an executive summary to the Department or Program Chiefs, Medical Record Services, Patient Accounts and other key senior and executive leaders.
The auditor will further be expected to present the analysis and recommendations that are used to evaluate compliance with the relevant healthcare regulations and provide technical and educational assistance to various staff to ensure related process improvement.
Required Minimum Knowledge, Skills, and Abilities (KSAs)
- Eight or more years combined experience in coding, billing, documentation improvement, clinical practice, payer claims adjudication, and/or compliance. A broad knowledge of medical terminology, anatomy and physiology, pathophysiology and disease process is required. Three to five years’ experience with medical auditing, research, and chart review is necessary.
- Possess one or more of the following certifications: CPC, COC, RHIT, RHIA, CCS, or CCS-P. Additional certifications including CPMA, CHC, or CPCO are preferred.
- HS Education required, 2-4 year degree in a related field is preferred.
- Must have in-depth knowledge of teaching hospital, provider-based medical and behavioral health practice organizational structure. CAH, RHC, Home Health and FQHC experience is helpful.
- Knowledge of physician and hospital billing practices, CMS regulations, CPT coding guidelines from the American Medical Association, ICD-10-CM and PCS along with DRG methodology, as well as knowledge of the AHA Coding Clinic, commercial payer guidelines, state and federal healthcare regulatory guidance and the ability to research and analyze this information within the structure of a healthcare audit.
- Ability to analyze and interpret clinical and administrative healthcare data and communicate at a college level, in both verbal and written formats.
- Ability to be sufficiently self-motivated to organize and manage the extensive planning, research, processing, collection, maintenance and analysis of compiled information and the preparation of reports from this data.
- Ability to establish and maintain effective and ethical working relationships with physicians, administrators, supervisors, outside agency personnel, and all levels of hospital personnel in relation to appropriate documentation practices and compliance.
- Ability to maintain the strictest confidentiality in the performance of duties.
- Proficiency in Microsoft Office is required. Epic, or other healthcare EHR experience is preferred.
- Ability to maintain the stamina, focus and accuracy required to perform detailed reviews and audits on a continuous basis.
- Ability to work as scheduled, independently and in a team environment and with minimal supervision.