Description:
We are seeking an elite, detail-oriented Medical Billing Auditor to evaluate our revenue cycle operations, ensure rigorous regulatory compliance, and safeguard financial integrity. The ideal candidate possesses deep expertise in multi-specialty coding, payer-specific guidelines, and federal healthcare regulations. You will serve as the final checkpoint between clinical documentation and clean claim reimbursement, proactively identifying systemic errors, mitigating compliance risks, and optimizing overall revenue capture.
Key Responsibilities
- Comprehensive Claims & Chart Auditing: Conduct meticulous pre- and post-submission audits of medical records, claims, and electronic health record (EHR) entries to verify that documentation fully supports billed services.
- Denial & Variance Trend Analysis: Perform deep-dive root-cause analyses on recurring claim denials, underpayments, and coding variations. Translate findings into actionable strategies to lower rejection rates and prevent future revenue leakage.
- Regulatory & Compliance Oversight: Ensure strict adherence to changing local, state, and federal guidelines, including Medicare/Medicaid policies, NCCI edits, HIPAA privacy regulations, and Office of Inspector General (OIG) compliance standards.
- Cross-Functional Education & Training: Develop and deliver targeted training sessions and constructive feedback loops for physicians, clinical documentation improvement (CDI) specialists, coders, and billing teams to correct systemic documentation gaps.
- Policy & Process Optimization: Partner with revenue cycle leadership to update internal billing policies, design robust audit frameworks, and refine charge capture workflows.
- Fraud, Waste, and Abuse (FWA) Detection: Actively monitor billing patterns for anomalies, outliers, or suspicious activities that deviate from standard medical and billing practices, escalating compliance risks immediately.
- Audit Reporting: Prepare high-level analytical reports, dashboard summaries, and risk-assessment matrices for executive leadership to drive informed financial decision-making.
Required Qualifications & Skills
- Experience: Minimum of 3 years of hands-on experience in medical billing, coding, and comprehensive revenue cycle auditing within a hospital, multi-specialty clinic, or health insurance setting.
- Technical Fluency: Expert-level command of ICD-10-CM, CPT, and HCPCS coding systems, along with modifier usage, global surgical packages, and bundling rules.
- Payer Literacy: Deep familiarity with diverse commercial payer contracts, Medicare/Medicaid regulations, and institutional billing guidelines.
- Analytical Prowess: Advanced data analysis skills with proficiency in auditing tools, EHR/EMR platforms (e.g., Epic, Cerner), and advanced Excel or healthcare intelligence reporting software.
- Communication Skills: Exceptional interpersonal, written, and verbal communication skills—capable of tactfully explaining complex coding rules and audit outcomes to clinical and administrative staff.