Hospital Bill Auditor

Company: Generali Global Assistance North America
Location: Pembroke Pines
Posted on: February 23, 2021

Job Description:

Job Summary:Position reports to the Director of Claims and is responsible for conducting bill audits on all high dollar cases > $25K for out-of-network, PPO and HMO claims. Analyzes and evaluates hospital charges listed within the UB04/Itemized Bill are supported within the hospital facility notes and/or treatment log. The incumbent will work closely with both network and negotiations towards charge reduction. Draws on advanced coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.Principal Duties and Responsibilities:* Perform hospital charge audits on all high dollar claims and as needed on other questionable charges applicable to outpatient/professional services.* Document all unsupported charges identified in the course of an audit in the audit report for each case. * Effectively interact and communicate with other associates, account managers and providers regarding all steps of the audit process. * Ensures that daily reviews are completed in a timely manner and meets both individual and department metrics. * Perform remote or onsite hospital bill charge audits as assigned * Response to coding questions from outside departments and provides coding references and guidelines* Prepares written reports of the audit findings and any potential dollar savings achieved* Plans and organizes work assignments to complete audits in an efficient and timely manner* Works closely with SIU to identify potential Fraud, Waste, and Abuse. * Responsible for maintaining current knowledge of CMS Official Coding Guidelines, current CPT, ICD-10, and HCPCS coding, fee schedule reimbursement methodology, and reimbursement.Required / Desired Knowledge, Experiences and Skills:* Medical Coder Certification from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) is required. * Requires strong clinical experience and technical skills* Strong working knowledge of AMA, CMS and other regulatory compliance guidelines and mandates. * Understanding of Medicare Reimbursement, Case Rates and DRG payment systems and guidelines. * Experienced with standard claim form UB04/CMS-1500 and international invoices. * Three years' experience with managed care organization, TPA, government agency preferred.* 5+ years solid background in all aspects of professional coding and bill audit* Able to grasp new concepts quickly and become proficient in incorporating the GMMI philosophy regarding Providers, Customer Service and Client Management* Ability to manage and prioritize multiple tasks coupled with excellent communication skills (verbal & written)* Excellent interpersonal skills necessary to interact positively with both internal and external customers* Must represent GMMI in a professional and knowledgeable manner* Computer skills essential to manage correspondence, database maintenance, spreadsheet analysis and for information entry / retrieval from the systemEducation/Certifications:* Active Registered Nurse (RN) License* Certified Professional Coder (CPC), CIC and COC* Certified Professional Medical Auditor (CPMA)Physical Working Environment:While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified.GMMI is an Equal Opportunity Employer M/F/Disability/VeteranPowered by JazzHRKw9P1sjoDT

Keywords: Generali Global Assistance North America, Pembroke Pines , Hospital Bill Auditor, Accounting, Auditing , Pembroke Pines, Florida