Auditor - Health Alliance Plan - Troy
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 of 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.
- Coding Credentials: (e.g., CPC, CCS-P, CPC-H, CCS, RHIA, RHIT)
Overview
Henry Ford Health System, one of the largest and most comprehensive integrated U.S. health
care systems, is a national leader in clinical care, research and education. The system includes
the 1,200-member Henry Ford Medical Group, five hospitals, Health Alliance Plan (a health
insurance and wellness company), Henry Ford Physician Network, a 150-site ambulatory
network and many other health-related entities throughout southeast Michigan, providing a
full continuum of care. In 2015, Henry Ford provided $299 million in uncompensated care.
The health system also is a major economic driver in Michigan and employs more than 24,600
employees. Henry Ford is a 2011Malcolm Baldrige National Quality Award recipient. The
health system is led by President and CEO Wright Lassiter III. To learn more, 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. Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. My Choice Rewards is a program as diverse as the people it serves. 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. 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.
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.