Audit and defend revenues earned using the appeal processes appropriate for that payer. Ensure regulatory compliance in clinical departments by partnering to strengthen documentation, accuracy of code selection, number of units charged, to assure compliance and perfect the financial records. Educate and support the clinical department Managers / Directors or their designees to strengthen compliant service processes through implementing regulatory guidelines. Grow and keep concurrent with commercial policy and Medicare regulatory manual, Local Coverage Determination, and National Coverage Determination changes.
1. Review and analyze external auditor findings for determination of appeal
processes or for internal departmental education actions by applying case
scenario findings to the audit and coverage policies, as well as the coding
clinics as appropriate.
2. Capture, defend, and support earned revenue using the payer specific
coverage and appeal guidelines.
3. Strengthen revenue defense with proactive internal audits which focus on
medical necessity, documentation requirements and specificity, DRG affected
co-morbid conditions (CCs) and Major Co-morbidities or Complications (MCCs),
query practices, improving physician documentation.
4. Collaborate with Practitioners, Department Directors, and Managers to defend
revenue, and assist with clarifying regulatory or policy questions.
5. Support hospital departmental implementation and assurance of compliance of
conditions of participation and coverage criteria through seeking clarity of
directives and collaborating to address barriers.
6. Assure personal knowledge is current of: correct coding initiatives, AHA coding
guidelines for inpatient and outpatient hospital services, regulatory coverage
criteria, reimbursement criteria, commercial payer policies for coverage, audit
and appeals, as well as all documentation requirements as directed through
CMS manual updates, LCD and NCD updates, Program Memorandums,
Commercial Payer and Audit policies.
7. Track all external audit activity, correspondence, appeal outcomes, and actions
related to these efforts using the software, electronic folders, and appeal
spreadsheets as directed in the appropriate Standard Operating Procedures
and Policies for these tasks.
8. Learn and maintain knowledge of the Exeter Hospital medical records and
account software, the Medicare FISS software, and Excel and Word software at
a level that promotes smooth processing of tasks for this position.
9. Identify, report, and communicate audited service areas at high risk for
reimbursement issues and with finding trends. Analyze the information and
implement communication for change when an opportunity is discovered.
10. Performs other duties as assigned.