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Clinical Auditor


Department Description: We are conveniently located at 1135 Tremont St. Our offices are tucked in neatly next to the college campus of Northeastern University. Within walking distance are Symphony Hall, the Huntington Theater, the New England Conservatory of Music, and the Museum of Fine Arts. If it’s a nice day, we are just a home run trot away from Fenway Park.
For easy access to the rest of city and the suburbs, both the Commuter Rail and the Orange line are located right next door.

Our department offers flexible hours, casual dress and the panache of working for a world class medical institution.

We take pride in supporting the patient first mission of Beth Israel Deaconess by managing the revenue cycle and offer an incentive program to all employees to encourage the best financial results possible.
Our department offers diverse professional opportunities by interacting and supporting clinical area operations, by implementing cutting edge systems and by our commitment to a work/life approach to business.

Come work and grow with the Revenue Cycle Department of Beth Israel Deacones

Job Location: Boston, MA

Req ID: 28051BR


Job Summary: The PFS Clinical Auditor resolves coding edits and denials on a daily basis and conducts and/or assists with medical record and charge ticket audits as directed. The auditor will communicate and collaborate with the revenue integrity team to identify issues based on data trends from edit, denial and audit activity related to coding and/or billing. The auditor participates with the revenue integrity team in the development and implementation of problem resolution with clinical departments as appropriate. Ensures compliance with applicable laws and regulations and performs other related duties as assigned.

Essential Responsibilities:
  1. Reviews and processes all claim edits in the various coding databases in the department using current coding, billing guidelines and medical record documentation to resolve issues with medical necessity, modifier usage with NCCI edits, missing, invalid or incorrect ICD -9, ICD- 10, CPT and HCPCCS codes and MUE edits.
  2. Based on coding changes and data trends in the edit/denial coding databases, communicates and collaborates with members of the revenue integrity team to identify areas needing remediation due to a systems issue, CDM maintenance or performance problems in clinical departments related to coding and billing activities. Assists in the development and implementation of corrective action plans.
  3. Using coding knowledge and background, provides the medical coding requirements and guidelines related to ICD ' 9/ICD-10, CPT and HCPCCS codes to members of the revenue integrity team and assists in the preparation and development of training and educational material to ensure clinic staff receives adequate training to resolve identified problems.
  4. Maintains knowledge of current coding issues, guidelines and changes; documents and communicates changes to department staff and provides training as required. Identifies charge ticket issues and communicates issues to appropriate department managers or CDM team as appropriate.
  5. Assists the Director of Payer Audits in resolving private or government payer audits that relate to coding issues by reviewing the coding issue identified. Provides the correct coding and billing guidelines to resolve the issue identified as well as any suggestions for a corrective action plan.
Required Qualifications:
  1. High School diploma or GED required. Associate's degree preferred.
  2. 3-5 years related work experience required.
  3. Must be a Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Professional Coder (CPC) in good standing.
  4. Common Procedural Terminolgoy (CPT), International Classification of Diseases (ICD-9), and Health Care Procedural Coding System (HCPCS) coding experience required.
  5. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
Preferred Qualifications:
  1. Prior experience in hospital outpatient coding and medical record audits.
Competencies:
  1. Decision Making: Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.
  2. Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.
  3. Independence of Action: Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.
  4. Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.
  5. Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.
  6. Knowledge: Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations.
  7. Team Work: Ability to lead collaborative teams for larger projects or groups both internal and external to the Medical Center and across functional areas. Results have implications for the management and operations of multiple areas of the organization.
  8. Customer Service: Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally

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