Auditor Payment Integrity (Hybrid - Troy, MI) - Health Alliance Plan
🔍 Troy, Michigan
General Summary:
The auditor is responsible for analyzing and auditing inpatient and professional claims to identify inappropriate coding and billing practices/patterns, including those related to unbundling, upcoding, investigational services, and non-medically necessary services. The auditor is responsible for researching, interpreting, and applying HAP specific policies and contract provisions. The auditor will negotiate with client and hospital representatives to resolve identified issues on a case-by-case basis. The auditor will request medical records from providers and conduct medical record audits.
Principal Duties and Responsibilities:
- Review of Claims Payments
- Assist in formulating plans to develop an ongoing process to identify opportunities for recovering erroneous or fraudulent claims.
- Analyze various billing issues and make recommendations to the appropriate departments for improvements.
- Utilize internal software to analyze provider payment patterns and identify cost saving opportunities.
- Review paid claims for various contract changes and conclude on accuracy of payments.
- Work with providers to collect monies due to HAP in cases of overpayments.
- Identify, evaluate and assist in the implementation of other opportunities for cost savings (not necessarily related to claims payments) or revenue enhancement through operational audits or other means.
- Examines random claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.
- Performs medical record audits including audit of claims, rate tables, fee screens, and other payment mechanisms to ensure accurate payment of financial obligations in accordance with policies and procedures and contractual arrangements and benefit design.
- Keep current with industry fraud, waste, and abuse trends and activity both local and national level.
- Perform root cause analysis and submit recommendations for appropriate change management when audit findings do not reflect accurate payments (i.e., over or underpayment findings).
- Assist in the preparation of the annual audit work plan.
- Investigate fraud, waste, and abuse allegations through interviews, data analysis, and medical record audits.
- Assist in keeping department policies and procedures current along with being a subject matter expert to other departments regarding coding and documentation guidelines and requirements.
- Perform additional duties as required.
Education/Experience Required:
Bachelors’ Degree in Health Administration or related field. Relevant or related experience may be considered in lieu of academic requirements. Related experience is defined as six (6) years’ experience in claim audits or medical record audits.
Minimum three (3) years of claim audit, medical record audit or professional audit experience.
Minimum five (5) years’ experience working in the health care industry.
Knowledge of CPT, HCPCS, and ICD-10 coding systems and working knowledge of healthcare compliance are required.
Ability to work with and interpret claims data and medical record documents and communicate effectively with providers, and members.
Ability to work with automated financial systems.
Must be able to demonstrate ability to design complex spread sheet based and database applications.
Knowledge of medical claims data and managed care membership data.
Knowledge of industry claims, healthcare and medical terminology.
Proficient with health care claims data and payment methodologies.
Knowledge of CPT, ICD-10, HCPCS, APC and DRG’s.
Knowledge of Medicare and Medicaid reimbursement methodologies.
Knowledge of anatomy, physiology, disease-process, medical terminology, pharmacology, and coding systems.
Strong initiative, well organized, and possess strong problem-solving communications skills and be able to work independently.
Certifications/Licensures Preferred:
· Coding Credentials: (e.g., CPC, CCS-P, CPC-H, CCS, RHIA, RHIT)
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.