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*Description*

*Summary:*

The Charge Integrity Auditor performs detailed chart to bill audits of inpatient or outpatient medical accounts, comparing the medical record documentation with the itemized bills, procedures, and department documented charging practices across the Nuvance Health System. The Charge Integrity Auditor coordinates and reports audits savings or losses for the facilities and medical groups, data processing errors, the performance of the hospitals and physician charging systems as well as documentation and justification with the medical record and itemized bill. Ensures complete charge capture, is the subject matter expert on charging functions, workflows and analysis of the medical record. The audit process begins with registration, orders and clinical workflows. Ensures that the charge triggers work and that clinical documentation supports charges. Assists in the development of a charge reconciliation process for all applicable departments.

*Responsibilities:*

1. Completes concurrent reviews of hospital and physician bills to document unbilled, under billed and over billed items and services.

a. Reviews individual charge procedures related to each case, identified correct service codes on supplies and/or services.

b. Performs review for carve out exclusion to identify specific implantable devices.

c. Acts and a consultant to Service Lines and Business United to ensure an accurate Soarian Financials build, including service mapping, accurate price list linking, bill item codes, and accurate SPSIDs codes.

d. Test all charges and ensure that interfaces between systems are working as designed.

e. Maintains records, as required, by Auditing and Regulatory Agencies.

f. Assists in the maintenance of the CDM Software scrubber tool, including managing and auditing the edit logic, develops KPIs reports and tracks improvements.

2. Liaises with other hospital departments as well as the physician medical groups and serves as a point person of contact for charge capture improvement opportunities

3. Creates, updates and maintains charge protocol manuals for each service area reviewed.

4. Communicates and works with all internal and external customers.

5. Strong knowledge in charge codes, charge viewer, CPT/HCPCS codes.

a. Responsible to review charge documentation, charge triggers and all relevant systems.

b. Assist the clinical areas by reviewing the Charge Error Work List and EBEW to ensure that trends are identified and resolved timely.

c. Ensure that charge codes are accurate and interfacing correctly from point of registration through delivery to bill.

d. Investigates and documents any potential for new programs and product development.

6. Identifies compliance risks and financial opportunities based on chart reviews, charge error work lists and a regular review of unbilled accounts.

7. Reviews audit action plan with Charge Integrity Leadership and Team, ITG Teams, Coding and clinical departments for the hospitals and physician groups for input on resolutions.

a. Work closely with Compliance.

b. Assist in the development of a daily charge reconciliation process to ensure that charging is accurate and documented.

c. Provide feedback and education to the clinical departments when charges are not captured and work through resolution.

d. Prepare and summarize findings, including extrapolation, of all audits.

8. Participates in and leads inter-departmental process improvement opportunities.

9. Initiates quarterly and annual CPT/HCPCS updates in accordance with published guidelines from the AMA and CMS

a. Tests and validated charge changes to ensure charge triggers result in charging for the new/revised code.

b. Manages and presents relevant materials at the CDM work group sessions, assists in the development of the agenda and communicates next steps to interdisciplinary group. Maintains a tracking tool for project managed and regulations.

c. Maintain compliance with Federal, State and Payer Regulations, including Pricing Transparency.

10 .Maintain and Model Nuvance Health Values.

11.Demonstrates regular, reliable and predictable attendance.

12.Perform other duties as required.

*Other Information:*

1.A Bachelor’s Degree (or equivalent) in Nursing, health-related field, Accounting, Finance, Management or related field and a minimum of five (5) years of related experience or an equivalent combination of education and work experience.

2.Certified Professional Coder (CPC) required. RN license preferred.

3.Strong analytic, qualitative, interpersonal and communication skills a must.

4.Proficient in payment review systems, hospital and physician clinical and billing systems (Cerner preferred) clinical record information systems, and coding methodologies.

5.Ability to understand and interpret medical records, hospital bills, physician bills, and the charge master along with the ability to understand all ancillary charging and department functionality.

6.Knowledge in Managed Care, Medicaid and Medicare and payment methodologies to ensure charging is in alignment with regulatory requirements.

7.Previous auditing experience preferred.

8.Experience with Word, Excel, graphics and strong database applications desired.

9.Proficient in payment review systems, hospital and physician clinical and billing systems (Cerner preferred) clinical record information systems, and coding methodologies.

Working Conditions:

Manual: Little or no manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Nuvance Health

Org Unit: 1814

Department: Charge Integrity

Exempt: Yes

Salary Range: $32.23 - $59.86 Hourly

We are an equal opportunity employer

Qualified applicants are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other classification protected under applicable Federal, State or Local law.

We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation or our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to ensure that you are considered for current or future opportunities.