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)
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health 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.