Auditor
Company: Community Health Group
Location: Chula Vista
Posted on: March 15, 2023
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Job Description:
Community Health Group is a locally based non-profit health plan
that ensures access to high quality, culturally sensitive health
care for underserved communities throughout San Diego County. We
treat our 300-member, multi-lingual staff like family, encouraging
an atmosphere of collaborative teamwork, continuous learning,
personal growth, and promotion from within. Recognized as one of
the Top Workplaces in San Diego, CHG offers its employees such
benefits as tuition reimbursement, a meditation room and yoga
classes, a monthly Breakfast With The CEO, and memorable events
throughout the year. We know that by serving our employees well,
they, in turn, will better serve our nearly 300,000+ membership. We
have been recognized consistently for the excellence and
sensitivity of our customer service by members, physicians,
vendors, and a full range of health care providers. We are
accredited by the National Committee for Quality Assurance and
proud of our continuing company-wide Quality Initiatives. We are
currently recruiting for: TITLE: Coding Compliance Auditor Target
Hiring Range: $ 24.29- $27.93 Per Hour EEO1: Administrative Support
Worker POSITION SUMMARY Audits medical records to ensure compliance
with coding procedures and standards, based on CHG's protocols,
regulatory requirements (CMS, DHCS, DMHC), and American Medical
Association (AMA). Reviews and provides processing recommendations
on routes from Claims Disputes and Claims Department. Collaborates
with CMO to review medical records to validate claim
determinations. Identifies training needs for Claims and Provider
Services department. Ensures compliance with coding, fee-schedule,
and system changes. Works closely with department leadership to
improve efficiencies, make recommendations that will support the
departmental goals and provide resources and education to Claims
and Provider Services Departments. COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that
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
including CMS and Medi-Cal. RESPONSIBILITIES Audits and reviews
medical records to provide resolution on claim dispute routes and
claim routes (emergency claims down coding, modifier payment
reduction, modifier payment increases, medically unlikely edits
(MUE), Virtual Examiner NCCI edits, implants with a payment greater
than $10,000), and invoices. Works closely with CMO to review
medical records to validate claim determinations, identify FWA
through medical record review, and resolve pending dispute cases to
meet compliance. Assist Claims, UM, Contracting, and IS Department
with CPT, HCPCS, and ICD-10 related coding projects (contracts,
reports, etc.). Ensures fee schedule updates are identified
accordingly (PDPM, AB1629, Hospice rates, etc.). Make process
related recommendations on medical coding changes to meet coding
compliance. Assists with adjustment projects as it relates to
coding, fee-schedule, or system updates. Provide research, and
other support services to ensure observance with official coding
policies, regulations, requirements, and standards. Through the
review of provider disputes, identify training opportunities for
the Claims team and Disputes team. Submit written recommendations
to Claims Compliance Supervisor. Reviews literature and regulatory
guidelines for claims processing updates including Medi-Cal,
Medicare, and National Correct Coding Initiative (NCCI). Analyze
NCCI coding software reports for accuracy. Audit disputes denial
language (written determination) to ensure written explanation is
clear, accurate, and appropriate. Maintain and update desktop
procedures related to coding or fee schedule changes. Candidate
must maintain credentials and be in good standing with
credentialing organization. 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. Education: Certified Professional Medical Auditor
Certified Professional Coder Bachelor's Degree preferred.
Experience/Skills: A minimum of five years of experience in claims
adjudication and medical record auditing. Strong knowledge of
AB1455 regulatory requirements, CMS and Medi-Cal billing
guidelienes, CPT and ICD 10 coding, and medical terminology.
Ability to read, analyze and interpret regulations and contract
language. Excellent customer service skills. Good technical writing
skills. Good judgment and problem-solving skills; team player; and
ability to work independently. Physical Requirements: Prolonged
periods of sitting and frequent walking. May be required to work
evenings and weekends. 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. Employment Type: Full
Time Years Experience: 3 - 5 years Bonus/Commission: No
Keywords: Community Health Group, Chula Vista , Auditor, Accounting, Auditing , Chula Vista, California
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