What are the responsibilities and job description for the Internal Auditor/ Certified Professional Coder position at Cancer Care Specialists of Illinois?
SUMMARY: Under the general supervision of the Director of Business Office Services, the Internal Auditor/ Certified Professional Coder is responsible for the identifying and implementation of documentation and billing functions. All payors and CCSI specialties are included. The Internal Auditor/ Certified Professional Coder utilizes internal and external resources to create, identify, present and monitor new and changing documentation and reimbursement trends and exceptions. The Internal Auditor/ Certified Professional Coder assist with education, training and mentorship of CPCs within the practice. In the absence of the Patient Financial Services Supervisor, the Internal Auditor/ CPC coordinates the general activities of the Prior Authorization Department to ensure smooth and efficient services. Is also responsible for training Business Office staff, researching current medical policies and answers staff and provider questions based on current coding guidelines. Will review billing processes, reimbursement, and medical policies of FDA, NCCN, NCD, LCD, ICD10, CPT, HCPCS, and modifiers to ensure accuracy.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Business Office Duties
- Conducts advanced billing and coding training for Inpatient visit, Radiation Oncology and Behavioral Health billing staff to include charge entry, coding, reimbursement, and aged insurance reporting
- Researches medical oncology, radiation oncology and imaging medical policies, provides education and assistance to the Lead Patient Financial Services Supervisor.
- Researches medical policy denials, related insurance and billing issues.
- Explains medical policies to staff members of Patient Financial Services and Billing.
- Communicates denial reason to providers, prior authorization supervisor, and prior authorization staff.
- Requests & reviews evidence and articles from providers to support treatment outside of FDA or payor medical policy guidelines pre and post service dates.
- Provides documentation and evidence for medical policy denials to Medical Appeal vendor. Makes suggestions for successful argument. Reviews vendors appeal letters with providers prior to submission of appeal.
- Auditing/Compliance Duties
- Monitors Medical Oncology, Radiation Oncology and Behavioral Health reimbursement policies and adherence to billing and reimbursement policies.
- Serves as a liaison between coders, management and providers.
- Coordinates and responds to request of external auditors and providers.
- Prepares, coordinates and participates in hearings with CMS Administrative Law Judge and Fair Hearings.
- Completes required chart audits and requests necessary documentation from Medicare certified departments.
- Monitors Medicare, State and Federal reporting for each provider to ensure they are meeting the requirements, communicates their status to each, and coordinates the timely filing of data to the registry or government agency.
- Researches standards and participation requirements for implementation of CMS demonstration and quality programs prior to deadlines.
- Along with the Director of Business Office Services, establishes and maintains the governmental quality initiative reporting, utilizes or establishes written policies, conducts training, and reports progress to Providers.
- Conducts compliance training for all Business Office staff. Monitors adherence to correctness and compliance of coding and billing staff.
- Reimbursement Duties
- Services as backup biller as requested. Codes procedures and diagnosis. Reviews charts and abstracts data from patient records for documentation to support charges and services, analyzes source documentation to determine diagnoses, and selects codes for optimal reimbursement.
- Validates and posts charges for services, including charges for office visits, physician services, laboratory testing, treatments, etc. Reviews EMR documentation, including, office notes, nursing Medication Administration Report, progress notes, lab results, orders, and pharmacy lists for completion, enters charge ticket data, batches charge tickets, files completed batches, and posts charge adjustments.
- Specialized Drug Charges
- Reviews specialized drug charges for accuracy and compliance, codes and processes drug claims, and receives and posts reimbursement for specialized drug claims.
- Reviews returned, disputed or rejected specialized drug payment claims and resolves claim problems.
- Conducts orientation and in-service training on appropriate guidelines for usage, pretests, etc., to ensure proper documentation and payment of specialized drug charges.
- Research
- Serves as liaison between DMH Research Dept and CCSI billing dept. Reviews and releases monthly invoice and monitors for payment.
- Specialized Training and Resource Functions
- Attains AMA or AHIMA CPC and CPMA Internal Auditor certification. Completes required CEU.
- Conducts orientation and in-service training for new Providers and management staff.
- Serves as a resource person for providers regarding selection of procedure, diagnosis code, and payor medical policy requirements related to hematology/medical oncology policies, radiation oncology, and behavioral health.
- Is an expert in areas of Behavior Health, Medical Oncology/Hematology, and Radiation Oncology billing and coding.
- Trains & monitors providers on the Federal and State reporting requirements and reviews reporting statistics and documentation.
- Assists and provides coverage for the Patient Financial Representative, as needed, to complete prior authorizations.
- Professional Communications
- Maintains confidentiality in matters relating to all aspects of employment, including patient/family/significant other confidentiality.
- Interacts with patients/family/significant others with a variety of developmental and sociocultural backgrounds.
- Maintains professional relationships and conveys relevant information to other members of the health care team.
- Internal Contacts: Providers, nursing staff, laboratory staff, pharmacy staff, office staff, other Business Office staff, etc., and staff at other CCSI facilities.
- External Contacts: Vendors, contract maintenance personnel, insurance representatives, Medicare representatives, hospitals, other physician offices, hospice staff, etc.
- Relays information appropriately over telephones, facsimiles, e-mails, and other communication methods, and follows-through as needed.
- Communicates appropriate information to physicians, supervisors, and/or other members of the healthcare team as needed, and follows-through on physician orders and requests.
- Teamwork
- Encourages teamwork and works collaboratively as a health care team member.
- Assists with tasks necessary for the general operation and organization of the Business Office.
- Maintains positive attitude with patients, family/significant others and coworkers.
- Professional Development
- Attends staff meetings and mandatory in-services.
- Participates in continuing education opportunities.
- Contributes to the quality of patient services and participates in quality improvement initiatives.
OTHER DUTIES:
- Complies with all applicable safety and health regulations, policies and procedures. Complies with established personal protective equipment requirements necessary for protection against exposure to blood and body fluids, other potentially infectious material, chemical disinfectants, and other hazardous substances.
- Performs other duties as assigned.
EDUCATION/QUALIFICATIONS: High school graduate or equivalent. CPC and CPMA Certified or College degree in business administration, health care management or a related area preferred. Previous experience in medical billing, coding and collections. Preferred oncology billing experience. Must complete EPIC training and successfully pass required tests.
KNOWLEDGE/SKILLS/ABILITIES: Knowledge of medical terminology, anatomy and physiology, clinical medicine, diagnostic tests, radiology, pathology, pharmacology, and other medical specialties related to medical oncology/hematology. Extensive knowledge of CPT-4, ICD-10 CM, and HCPCS coding systems, governmental regulations, protocols and third-party requirements, as well as compliance issues related to billing and billing documentation. General knowledge of basic manual and computerized accounting and billing systems. Verbal and written English communication skills. Eye, hand, and auditory coordination. Basic computer skills. Problem solving and prioritization skills. Organization and interpersonal skills. Ability to work independently with minimal supervision and as part of a team; ability to work under pressure with time constraints; ability to meet deadlines and work with frequent interruptions; ability to concentrate, provide close attention to detail, and handle multiple tasks simultaneously. Ability to encourage teamwork; ability to coordinate the work of others; ability to coordinate daily Business Office operations to ensure smooth and efficient services. Ability to maintain professional attitude at all times; ability to handle telephone and face-to-face contact with patients, physicians and other staff. Ability to function in a sometimes demanding and fast-paced work environment related to changing patient needs, including work with patients with acute, chronic, and complex disease processes and those who are dying. Understands and practices patient confidentiality. A positive attitude towards health care team members and diverse patient populations.
PHYSICAL REQUIREMENTS OF JOB: Standing, walking, sitting, carrying, pushing, pulling, lifting, bending, stooping, squatting, crouching, twisting, reaching, handling, kneeling, and wrist and digital dexterity. Involves significant degree of data entry. Involves significant degree of sitting, and involves standing or walking for brief periods of time. Speaking, hearing, and visual acuity to communicate with patients, physicians and other health care professionals; use telephone system; and operate office equipment and computers. Exerting force (frequently up to 10 pounds and occasionally up to 20 pounds or more) to lift, carry, push, pull or otherwise move objects, including office supplies, medical charts, billing forms, etc. Limited driving.
MENTAL DEMANDS: Must be able to work under stress and adapt to changing conditions. Must be able to concentrate and focus on details.
WORKING CONDITIONS: Normal medical office environment. Job duties involve minimal potential for exposure to blood and body fluids, chemical disinfectants, and limited exposure to chemicals such as cleaning disinfectants and toners for office equipment.
BENEFITS:
- Health insurance
- HSA Option
- Dental insurance
- Paid Time Off (PTO)
- Sick Time
- Vision insurance
- 401(K) w/ match & profit sharing
- Life Insurance
- Short- & Long-Term Disability
