Health Care Services Auditor

Description

POSITION SUMMARY

Conducts internal audits of inpatient and outpatient referrals and oversees internal monitoring activities conducted by others to determine that core department activities are in compliance with established management control systems, policies, procedures, standards, and requirements.  Provides analysis and reports of audits to Health Care Services (HCS) department management and works with HCS team to implement and monitor corrective action.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations and accrediting bodies.

RESPONSIBILITIES

• Implements and maintains established audit/control systems and policies and procedures.
• Documents and maintains records of all audits performed.  Records include raw data or files reviewed, report of findings, corrective action plans, reassessment, and any ongoing monitoring logs.
• Investigates, reviews, and analyzes claims data by applying knowledge of established policy, practice and by data mining techniques to determine details of fraudulent erroneous, or abusive billing activity.
• Produces a written report to summarize audit scope and findings and recommended corrective action.
• Reports any audit concerns to HCS management without delay.
• Provides departmental education and training.
• Reassess a deficiency after a corrective action has been implemented and conducts on-going monitoring to ensure that deficiency does not reoccur.

• Oversees any monitoring functions that may be conducted by other department team members included but not limited to, inpatient and/or outpatient referrals, data integrity, and monitoring for fraud, waste, and abuse.
• In concert with HCS management, prepares documents for any external or internal audits and accreditation surveys.
• Assists in the development of new audit methodology and scope on an as-needed basis.
• Keep up-to-date with State and Federal regulations that apply to inpatient and outpatient case management.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Contributes to the team effort by accomplishing related results as needed.

• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
• Performs other duties as assigned.

Qualifications

EDUCATION   

• 4 year bachelor’s degree in healthcare related field is preferred but not required. 

EXPERIENCE/SKILLS

• Two or more years in managed care setting.

• Quality Management, Case Management or Utilization Management experience preferred
• Basic understanding of medical coding.

• Advanced knowledge of Microsoft Word, Excel, PowerPoint and Outlook.
• Excellent verbal and written communication skills, with the ability to clearly articulate thoughts and ideas.
• Organizational skills with the ability to handle multiple tasks and/or projects at one time.
• Customer service skills with the ability to interact professionally and effectively with providers, physicians, and staff from all departments within and outside the Company.
• Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization.
• Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements.
• Problem solving skills with the ability to look for root causes and implementable, workable solutions.
• Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization.

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.
• Prolonged use of computer.
• May be required to work evenings, weekends, and holidays.
• Some traveling may be required.

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.

Salary : $73,467 - $82,650