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Job Summary:

Provides audit support and guidance to management, providers, residents, and support staff in free-standing and facility-based practices.

Conducts assigned compliance audits for risk areas identified through the analysis of internal data and external sources.

Ensures all coding, billing, and documentation complies with federal and/or state regulations, private payor health care program requirements as well as the Care New England Compliance policies.

Responsible for auditing and implementing training programs to assist in achieving Care New England's goal of an effective compliance program.

Assists with new provider on-boarding education.

Duties and Responsibilities:

1. The Auditor must exhibit competence in Correct Coding Initiative (CCI), National Coverage Determinations (NCD), Hierarchical Conditionals Categories (HCC) and other federal payer policies and is expected to achieve mastery in the MPFS payment methodology, including the impact on Relative Value Unit (RVU) value related to Non-Physician Practitioner (NPP) services, Provider Based Billing (PBB) locations, and all other complex coding protocols within one year.
2. Consistently demonstrate a comprehensive, expert-level knowledge of inpatient and outpatient facility coding and billing in accordance with the rules, regulations, CMS, AMA, CPT, ICD-10-CM, and HCPCS Level II procedure and supply codes coding guidelines.
3. Effectively review/audit medical records with focus on Evaluation and Management services to identify opportunities for clinical documentation improvement and potential coding opportunities to optimize reimbursement.
4. Correctly identify and implement education and training opportunities related to coding for physicians and non-physician providers based on results of chart reviews under the direction of Care New England Medical Group management team.
5. Be consistently available as a subject matter expert for coding guidelines, questions, and other issues from Care New England providers and staff.
6. Assist physician practices and provider-based departments as a coding subject matter expert when necessary.
7. Provide baseline coding education to newly hired physicians and non-physician providers/clinicians on a timely basis.

Requirements:

Associate degree in Business Management or Health Care Management or a minimum of 3-5 years’ experience, with a strong emphasis on evaluation and management documentation, coding, billing, and auditing, preferably for a medium to large physician practice group or health system.

Multiple specialty coding experiences, including behavioral health preferred. Bachelor’s degree preferred.

Required Skills: A high-level knowledge of medical terminology, anatomy, and pathophysiology, along with understanding of the proper application of CPT procedure codes, HCPCS Level II procedure and supply codes, and ICD-10-CM diagnosis codes. Excellent verbal and written communication skills.

Preferred Skills: Evaluation and management coding and auditing expertise. Knowledge of billing, coding, clinical documentation regulations, and regulatory guidelines.

Proficient with technology and software tools, including but not limited to Epic and Cerner systems, and auditing tools such as MDAudit.

Proficient knowledge of MS Word, Excel, and PowerPoint required.

Certifications:

Required: Certified Professional Coder (CPC). Certified in Healthcare Compliance (CHC) within 12 months of hire.
Preferred: Certified Professional Evaluation and Management Coder (CEMC) or Certified Professional Medical Auditor (CPMA).

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.