Medical Auditor Resume Samples

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J Schmidt

Jamaal

Schmidt

20863 Foster Vista

Detroit

+1 (555) 859 2505

20863 Foster Vista

Detroit

Phone

p +1 (555) 859 2505

Experience Experience

San Francisco, CA

Medical Auditor

San Francisco, CA

Brekke, Kunde and Hermann

San Francisco, CA

Medical Auditor

Recommends procedural improvements and training opportunities to management. Provides written audit reports to supervisor for review and approval
Performs Clinical Pathway Adherence audits for all assigned providers according to new regimen orders in IKM
Develop and provide educational material to physicians specific to their scope of practice
Responsible for providing billing compliance education to all physicians and advanced practice practitioners within the division
Provide feedback of audit findings to physicians and conduct post-audit training sessions as audit results dictate
Work with a team of great people
Assist with other audits such as hospital visits, consultations, compliance, charge entry, reimbursement and others as assigned

Dallas, TX

CQS Medical Auditor, Group Benefits

Dallas, TX

Towne, Durgan and Hintz

Dallas, TX

CQS Medical Auditor, Group Benefits

Functional level of expertise/SME in Behavioral Case Management, Rehabilitation Case Management, or Medical Management
Provide constructive feedback to Regional Vice President and field management regarding Group Benefit audit results and observations
Continued personal career growth, and participation in personal development planning process
Effectively communicate observations, findings, file ratings, and quality driver with internal customers at all levels of the organization
Travel up to 10%
Meet audit productivity goals, and through effective time management, planning and preparation, participate in focus reviews and special projects without sacrificing quality, detail orientation or calibration responsibilities
Model personal integrity and drive the importance of ethics and compliance throughout the business

present

Chicago, IL

Remote Medical Auditor Specialist

Chicago, IL

Cummings-Sporer

present

Chicago, IL

Remote Medical Auditor Specialist

present

Performs inpatient, ambulatory surgery, emergency room, outpatient and evaluation/management coding audits on coding colleague work
Provide remote colleague educational sessions on issues identified during the audit process
Communicate quality issues to Remote Manager and Remote colleagues
Provides educational services to colleagues
Performs DRG reimbursement, data quality/accuracy, physician services and compliance audits
Acts as liaison with colleague manager
Maintains strict patient, physician, hospital and colleague confidentiality and follows all federal, state and hospital guidelines for release of information

Education Education

Bachelor’s Degree in Related Field

Loyola University Chicago

Bachelor’s Degree in Related Field

Skills Skills

Work with a team of great people
Rapid growth; stable company
Research and detail-oriented with the tenacity to find claim specific data for a specific measure within a given period of time
Prior experience with research and either HEDIS measures or auditing data submitted as claims
5+ years of experience relevant ICD-9 coding or medical record audit experience in a consultative role
Understanding of codes for services based on diagnosis and procedure
Competitive Base Salary
Prior HEDIS experience
3+ years’ experience working in a Healthcare setting, physician practice, or hospital

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12 Medical Auditor resume templates

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Hedis Medical Auditor Resume Examples & Samples

5+ of years of relevant ICD-9 Coding or Medical Record Audit experience in a Consultative role
2-year associate degree through a technical school or community college
CPMA (Medical Auditing Certification) from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) or equivalent certification requirement
Experience can be in a physician’s office, hospital or insurance office setting
Prior experience with research and either HEDIS measures or auditing data submitted as claims
Computer savvy (30 to 40 wpm) and analysis capabilities in order to navigate CPT4 code and ICD9 DX based on HEDIS Technical Specification requirements

Hedis Medical Auditor Resume Examples & Samples

5+ years of ICD-9 coding experience or medical record audit experience in a consultative role
Strong computer skills and analysis capabilities
Understanding of codes for services based on diagnosis and procedure

Medical Auditor Resume Examples & Samples

Work with a team of great people
Rapid growth; stable company
Competitive Base Salary
Completes audit work papers by documenting audit tests and findings
Communicates audit findings by preparing a final report; discussing findings with auditees
Writes appeal letters to payers
Conducts defense audits from payers
Charge audits/reviews. This includes but not limited to government, patient, health system or payer
Works closely with PFS in reviewing accounts for charge accuracy
Works with departments at the facilities on charge capture
Perform internal retrospective, concurrent or prospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record, and that all coding/documentation combinations are compliant with Federal and State regulations
Maintains patient confidentiality and strict adherence to HIPAA guidelines
Registered Nurse Licensure (RN) and a Bachelor’s Degree in Nursing is desirable
3 to 5 years of experience in a clinical nursing environment
Knowledge of ICD-9 and CPT Coding Principles and billing methodologies
Has the ability to work independently under general supervision with considerable latitude for initiative and independent judgment
Has the ability to develop and incorporate new technologies in the audit process. Knowledge of Microsoft Excel and Word
Knowledge of nursing and clinical operation
Excellent interpersonal skills; excellent oral and written communication skills; excellent time management/prioritization skills; Strong problem solving and critical thinking skills; Good judgment

Medical Auditor Resume Examples & Samples

CPMA (Medical Auditing Certification) from accredited source or equivalent certification requirement
5+ years of experience relevant ICD-9 coding or medical record audit experience in a consultative role
2-year Associate Degree through a technical school or community college
Proven computer skills and analysis capabilities in order to navigate CPT4 code and ICD9 DX based on HEDIS Technical Specification requirements
Research and detail-oriented with the tenacity to find claim specific data for a specific measure within a given period of time
Basic Excel skills and must have the ability to type 30-40 WPM
Prior HEDIS experience

QMS Auditor, Medical Devices Resume Examples & Samples

Audit client management systems for compliance with established standards, client, and/or industry requirements, government regulations, and other relevant standards, specifically ISO 13485, ISO 9001, Canadian Medical Devices Regulations (CMDR), Medical Device Directive (MDD 93/42/EEC) and other requirements related to the medical device industry sector
Assist clients with questions relevant to the audit and/or certification process
Act as Lead Auditor or team member
Coordinate audit activity with team members
Liaison with client regarding audit activity
Review client's quality management system documentation
Verify and document evidence of compliance and non-compliance
Prepare audit report
Review audit results with coordinator and other assessment team members. Make presentations to clients and/or certification board concerning audit results, when required
Assist with corrective action requirements resulting from assessments
Participate in audit meetings
Review audit reports and provide technical assistance to the medical team
Support management in areas of continuous improvement
Provide management with updates on status of work, initiatives, and projects, as required
Travel will include overnight/multiple days, to various worksites and client locations
In-depth knowledge of auditing Management Systems in the medical device industry sector, demonstrated through a combination of education and experience
A minimum of 10 years of full-time work experience in medical device related industry
Completed lead auditor training for any standard, preferably ISO 13485 Lead Auditor training, but will train if needed
Advanced course work or training in Quality Management Systems
Relevant formal education equivalent to a 4 year college/university degree in the U.S. (biology or microbiology; chemistry or biochemistry; computer and software technology; electrical, electronic, mechanical or bioengineering; human physiology; medicine; pharmacy; physics or biophysics)
Sound judgment, organization and analytical skills
Excellent computer and writing skills
Ability to exercise effective time management skills in completion of assignments
Must be willing and able to travel extensively. Primarily domestic travel, but international travel may be needed (requires passport)

Auditor Medical Devices Resume Examples & Samples

BSc degree in discipline relevant to Medical Device manufacture in Science or Engineering, Electronics, or equivalent qualification,
Minimum four years’ experience in medical device industry, with at least two years related to the hands on Manufacture or design and development of medical devices
Must have knowledge of ISO13458 and Medical Device Directive
Previous Assessing internal , 2nd party Supplier or 3rd Party a distinct advantage but not essential
Previous recognised Auditor / Lead Auditor training also an advantage

Buck-senior Medical Claim Auditor Resume Examples & Samples

Manage and perform audits of medical claims payment data to validate conformance with specified coverage policies and payment methodologies as assigned
Review and understand the client’s Summary Plan Descriptions and Administrative Services Agreement
Work with IT to define the Plan parameters for use in reviewing electronic claim data within the audit software system
Travel to the administrator to conduct the site claim audit (Travel up to 60% of the year, Monday through Friday)
Work with Administrator to resolve exceptions, review supporting documentation and make final claim error determination
Ensure audit timeline is adhered to and deliver high quality service to clients
Prepare or assist lead auditor in preparing audit reports which clearly articulate the audit methodology and audit findings. Audit reports must be supported by work papers
Work collaboratively within the audit team as well as with internal and external customers
Participate in team meetings, conference calls, WebEx’s, etc remotely / locally with administrators and audit team as necessary
Assist in supporting lead auditors and Director as requested
4-6 years of experience in claim adjudication from a major insurance claims administrator or health plan environment
Knowledge of CMS rules and regulations
Must demonstrate a high level and familiarity of claims administration, including experience with medical, dental, mental health, prescription and Medicare
Self-directed individual who requires little supervision and can work effectively independently or in a team setting
Previous internal audit, third party external auditing and prior consulting environment experience a plus

Remote Medical Auditor Resume Examples & Samples

Performs DRG reimbursement, data quality/accuracy, physician services and compliance audits
Provides educational services to colleagues
Maintains current working knowledge of CPT and ICD-10 coding principles, government regulation, protocols and third party requirements regarding billing
3+ years coding of experience including inpatient and/or outpatient coding skills as well as ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
Ability to consistently code at 95% accuracy and quality while maintaining client specified production standards
Knowledge of medical terminology, ICD-10-CM and/or CPT-4 codes
Prospective payment methodologies, physician office billing

Remote Medical Auditor Specialist Resume Examples & Samples

Acts as liaison with colleague manager
Utilizes a laptop computer in a virtual office, windows-based environment
Must be colleague focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
Participates in staff meetings, trainings and conference calls as requested
Active RHIA, RHIT, CCS, CCS-P ,CPC or CPC-H
Associate’s Degree in relevant field preferred or combination of equivalent of education and experience
3+ years coding of experience including inpatient and outpatient coding skills as well as ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
Must successfully pass a coding skills assessment

Medical Device Auditor Resume Examples & Samples

Je hebt uitstekende contactuele en communicatieve vaardigheden en hebt een grote overtuigingskracht/zelfzekerheid met voldoend empathie
Je hebt goede kennis – in woord en schrift – van het Nederlands en het Engels en bij voorkeur minstens een bijkomende taal (Frans of Duits)
Je bent nauwkeurig nauwkeurig en beschikt over een sterk organisatievermogen
Volgende punten zijn zeker een meerwaarde
Goede kennis van de relevante wetgeving
Goede kennis van kwaliteitssystemen zoals ISO 13485

Medical Management Auditor Resume Examples & Samples

Develop and maintain the audit process and tools related to: authorizations, appeals, quality events, and case management in CMS; inter-rater reliability related to McKesson InterQual Suite; and data entry into the credentialing subsystem
Develop and maintain the audit schedule
Audit staff as outlined in the system auditing policies
Train audit staff at the health plan in the use of audit process and tools
Facilitate compliance with the auditing process
Act as a consultant related to system auditing to others in the unit, department and health plan
Work with staff to identify and resolve authorization load error report system problems
Coordinate auditing outcomes with the Trainer to identify, develop and publish corrective actions/educational material related to audit errors
Coordinate auditing outcomes and system maintenance with the Sr. Clinical Systems Specialist to resolve or enhance clinical systems
Bachelor’s degree in related field or equivalent experience
Must have a current Nursing License Issued by the State of South Carolina
Must have a valid Driver’s License and Insurance
Other Nice to have skills include
Strong Audit experience
Strong accountability and ethics
Ability to work with multiple individuals and levels of leadership
Past experience with CMS and regulations/compliance
Past experience as a trainer or manager

Medical Auditor Resume Examples & Samples

3 – 5 years acute facility nursing
Chart/bill audit experience
Must be able to maintain a high level of confidentiality
Works independently and is flexible with all job duties
3 – 5 years acute care facility nursing

Medical Management Auditor Resume Examples & Samples

Must have a current Nursing License Issued by the State of Arkansas
RN Auditing Experience Working remote Monday - Friday Schedule
Telephonic experience

Medical Device Lead Auditor Resume Examples & Samples

Conduct audits (either desk-based or on client’s sites) in accordance with established procedures, maintaining a high standard of service delivery that ensures effective customer relationships
Complete all chargeable work within the required budget and timeframes to ensure customer satisfaction and efficiency of the business
Complete specific projects in relation to medical device procedures, processes, systems and documentation as requested by medical devices operations manager
Ensure completion of all assigned work and relevant documentation in accordance with required procedures and standards to fulfil customer expectations
Project-manage auditing teams, as appropriate, to maximise efficiencies, enhance client satisfaction and ensure compliance with standards
If required, to provide technical support and staff training to all parts of the business in UK and overseas to enhance the service capability of the business
To manage personal expenditure required to fulfil the role in order that customer relations and profitability of the business are not compromised
To maintain a full knowledge and understanding of SGS procedures and external approval criteria to allow efficient and effective technical reviews
At all times, adopt a safe behaviour by exercising due regard for the health and safety of yourself, colleagues and clients, in line with the Company’s policies and procedures
Ensure full compliance with the Company’s Code of Integrity & Professional Conduct, and at all times adopt behaviour in accordance with SGS UK’s Equality & Diversity policy
Able to demonstrate an excellent working knowledge of medical device management systems, standards and medical device compliance/auditing techniques
Able to demonstrate a good knowledge of sterilization and non-active devices
Good knowledge of manufacturing of medical devices within a clean room and sterilization product standards
Effective interpersonal skills; able to develop good working relationships with people at all levels
IT literate i.e. competent in the use of MS Office applications and preferably experience of using large and complex databases
Willingness to learn and adapt to change – committed to continuous personal and professional development
Detailed understanding of the relevant medical device regulations for which audits/technical reviews are being undertaken
Work experience in positions with significant QA, Regulatory or management systems responsibility
Experience with Harmonised sterilization, clean-room and non-active medical device standards
Experience with Risk Management EN ISO 14971:2012
Industrial experience with medical device manufacturing that includes experience in the operation of the relevant sterilization processes i.e. experience as a practising microbiologist in support of such sterilization processes
Relevant technical application of the sterilization validation processes
Medical device experience from auditing/work
Experience auditing against recognised standards
Experience of working under own initiative and in planning and prioritising workloads
GCSE Mathematics & English Language, or equivalent
First degree, or equivalent vocational qualifications - i.e. BA/BSc, HND, Chartered Engineer, diploma etc in life sciences with microbiological aspect/modules or a microbiology degree
Full driving licence for use in the UK

Remote Medical Auditor Specialist Resume Examples & Samples

Responsible for creating and conducting QA audits and results on all new hires, new clients, as well as audits of tenured colleagues on new accounts
Complete all scheduled QA for clients per a predetermined schedule
Communicate quality issues to Remote Manager and Remote colleagues
Maintain reports and accuracy rates for colleagues/clients
Respond to client QA needs and requests
Demonstrated ability to deliver audit results to colleague and client when required
Provide remote colleague educational sessions on issues identified during the audit process
Assist in providing educational requirements for remedial training as needed
Support nThrive’s Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information
Commitment to maintaining up-to-date knowledge of current and changing regulatory requirements related to coding and compliance
Attend educational conference calls
Provide coding support as needed
Perform other duties as needed in the remote coding areaAbility to add, subtract, multiply and divide in all units of measure using whole numbers, common fractions and decimals
Ability to compute rate, ratio and percent and to draw and interpret bar graphs
RHIT or RHIA and/or CCS, CCS-P required
3+ years of experience in inpatient and outpatient coding and auditing required
Demonstrated experience in coding quality assurance audit functions within the Inpatient and Outpatient skill sets
Demonstrated customer service focus consistent with professionalism, flexibility, dependability, commitment to excellence and commitment to the profession
Must possess and display excellent interpersonal and problem solving skills with all levels of internal and external customers
Preferred skill sets: IP, Evaluation & Management, IVR, MS-DRG, OP/ASU, procedures, APC, physician office billing, prospective payment methodologies and charge description master review

Medical Auditor, Compliance Resume Examples & Samples

Attend department meetings and present educational update or discuss unique audit findings and recommendations as requested by the Compliance Manager
Complete, review, and submit summaries to Compliance Manager or appropriate department staff
Conduct post-audit compliance training sessions for PSD physicians and non-physician practitioners as audit results dictate. These training sessions will include, but are not limited to, provision of education specific to the issues found on audit and will be largely based on the documentation, coding and billing rules as set forth by CMS and other relevant Federal and State regulatory agencies
Consult with physicians and physician staff, as needed, on documentation issues, and other regulatory issues as they arise
Develop and manage relationships with colleagues in a professional, independent manner to create an environment that affects necessary change to systems effecting the documentation, billing or coding services
Perform internal retrospective, concurrent or prospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record, and that all coding/documentation combinations are compliant with Federal and State regulations
Report status of all assignments and pertinent information to Compliance Manager
Responsible for conducting special projects, which may include audits, as necessary. Special projects may require spreadsheet development as well as reports that summarize outcome of special projects
Responsible for evaluating process and/or operational issues throughout PSD
An associates degree or comparable technical school diploma is required
A minimum of 3 years experience in coding and documentation of physician services is required
Experience in an academic medicine environment preferred
Advanced ICD-9 and CPT coding, anatomy and medical terminology knowledge required
Proficiency in Microsoft Office
Must have knowledge of the physician billing process and medical record audit process
Must have knowledge of Medicare, Medicaid and local third party carrier regulations
Must be willing to travel within Western Pennsylvania
The Medical Auditor must be able to communicate effectively both orally and in writing, with people both internally and externally
Must be able to identify problems and problem areas, and bring them to an amiable solution
Must possess technical and professionals skills in financial analysis as well as interpersonal skills
Must possess the ability to develop audit plans and tests to assure strong, efficient management controls
Must possess analytical problem-solving skills as well as the ability to coordinate the work of others and communicate effectively with all levels of management

Medical Auditor Resume Examples & Samples

Responsible for providing billing compliance education to all physicians and advanced practice practitioners within the division
Conduct concurrent or retrospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient medical chart and that all coding/documentation combinations are compliant with Federal and State regulations
Completion of formal audit reports specific to audit findings
Provide feedback of audit findings to physicians and conduct post-audit training sessions as audit results dictate
Develop and provide educational material to physicians specific to their scope of practice
Consult with physicians and ancillary staff as needed on documentation and billing issues, requirements for supervision of resident services and other regulatory issues as they arise
Responsible for identifying potential areas of lost revenue as well as areas/issues that raise a compliance concern and communicating these matters to the Division Administrator
Attend pertinent Division meetings and present educational updates as needed
Must work closely and communicate with billing staff
An associates degree or comparable technical school diploma is required
A minimum of 3 years experience in coding and documentation of physician services is required
Experience in an academic medicine environment preferred
Advanced ICD-9 and CPT coding, anatomy and medical terminology knowledge required
Proficiency in Microsoft Office and ability to learn new software as needed
Must be self-motivated, with ability to work independently
Excellent analytical skills with ability to address multiple, complex tasks simultaneously and meet stringent deadlines
Must have knowledge of Medicare, Medicaid and local third party carrier regulations
Must have knowledge of the physician billing process and medical record audit process
This position not only requires the assessment and preparation of audit results but also the communication of those audit results to all affected parties
Excellent research, presentation and teaching skills with the ability to present to both large and small audiences
Must be willing to travel within Western Pennsylvania
The Medical Auditor must be able to communicate effectively both orally and in writing, with people both internally and externally
He/she must be able to complete duties and assignments independently, work effectively under pressure and deadline situations
Must be able to identify problems and problem areas, and bring them to an amiable solution
Must possess technical and professionals skills in financial analysis as well as interpersonal skills
Must possess the ability to develop audit plans and tests to assure strong, efficient management controls
Must possess analytical problem-solving skills as well as the ability to coordinate the work of others and communicate effectively with all levels of management

Medical Claims Auditor Resume Examples & Samples

Knowledge of CPT/HCPC/ICD9/ICD10 coding
Substantial knowledge of Medicaid, CMS, and commercial coverage regulations and guidelines
Claims processing
Computer experience required, including MS Access, Excel, Word, and PowerPoint
Ability to analytically and logically resolve issues and interpret findings
At least five (5) years in a managed care environment
At least three (3) years claims processing in HCFA 1500s, Dental, and UB04s

Medical Documentation Auditor Resume Examples & Samples

Core Audit Responsibilities: Using Kaiser Permanente auditing tools, conduct concurrent and retrospective audits of documentation supporting E/M, CPT and ICD9 codes assigned by clinical staff. Researches correct coding practices in relationship to applicable rules, regulations and coding conventions for billing to determine compliance with Federal, State and Kaiser Permanente regulations. Using independent judgment and sensitivity, reviews with individual physicians their audit findings, making suggestions for documentation improvements. Provides feedback to clinicians based on Federal and State government billing and coding guidelines. Plans, schedules and performs comprehensive chart audits to identify operational and regulatory issues related to coding, documentation, and compliance requirements and ensure complete and accurate data capture in compliance with Federal and State requirements
Permanente requirements. Designs and implements methodologies to ensure accurate and complete E&M, CPT and ICD9 coding audits. Provides technical expertise to Regional and local leadership to identify and resolve coding and chart documentation problems impacting the accuracy and consistency of coded data. Works with local Trainers to address operational processes that hinder encounter data capture. Reads and interprets medical data written by providers
Enters audit results into regional audit tools to support quality assurance process, regional analysis and regional training activities. Reviews analytical data and audit findings to identify coding trends and other risk areas. Recommends appropriate actions. Conducts quality assurance reviews. Collaborates in the development and execution of local audit and training plans. Partners with the EIO Managers to identify audit trends and risk areas based on audit findings and data analysis. Assists in developing and implementing policies and procedures / Compliance Audit Standards to ensure compliance with Federal, State and other regulatory requirements. Travel throughout the Northern California region based on operational needs may be required
Specific Audit Responsibilities - Claims and Referrals. In addition to the standard auditor accountabilities, the EIO Auditor is also responsible for conducting Claims and Referral audits. Responsible for independently implementing the end to end audit process for claims and referrals following established objectives with expected completion and accuracy goals. Partners with Provider Contracting to assess status of claims based on whether associated vendor is a contracted or non-contracted partner. Negotiation approach will need to be tailored to the type of vendor
Manage vendor relationship to get access to documentation which requires client management skills and travel to offsite locations. Develops a strategy to get access to pertinent medical record information and all supporting documents that need to be audited. Conducts audit independently on-site per audit objectives and guidelines
Minimum three (3) years CPT, ICD9 & E&M Coding experience
Experience using Epic electronic health record systems preferred
Experience using Web based applications preferred
Medical center operations or clinical experience preferred

Medical Claim Auditor Resume Examples & Samples

Review IT Audit Reporting, select and prepare valid audit sample following the standard departmental process and guidance received from the client
Travel to the administrator to conduct the site claim audit (potential for Travel up to 60% of the year, Monday through Friday)
Provide support to field auditors when requested – prepping reports, QA on IT reporting and audit reports, sample selection, etc
Provide recommendations to Administrator for corrective action as well as identify areas for further consideration for delivery to the client and claims administrator
Assist with Claims Data Analysis and Quality Assurance as requested
College degree (experience may be considered in waiving the degree requirement)
3-5 years of experience in claim adjudication from a major insurance claims administrator or health plan environment
Previous Audit/QA experience
Proficient in the use of Microsoft Office Software (i.e., Word, Excel, PowerPoint)
Strong organizational skills and the ability to efficiently prioritize multiple tasks
In-depth knowledge of ICD-9, CPT, HCPCS, revenue codes and medical terminology
Proficient with healthcare claim adjudication standards and procedures, including application of benefit plan designs, administrative services agreements, coordination of benefits and subrogation provisions
Excellent oral and written skills required
Team player with a strong work ethic

Remote Medical Auditor Resume Examples & Samples

RHIA, or RHIT plus CCS and CCS-P or CPC
Ten years coding and auditing experience including inpatient and outpatient coding skills as well as ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
Preferred coding skills: prospective payment methodologies, Charge description master review, physician office billing
Must successfully pass pre-employment coding test
Must be detail oriented and have the ability to work independently
Must display excellent interpersonal skills

Medical Auditor Resume Examples & Samples

Develops Audit and Education Programs
Performs Clinical Pathway Adherence audits for all assigned providers according to new regimen orders in IKM
Prepares reports of findings that details discrepancies and summarizes opportunities for improvement
Identifies trends that could be perceived as non-compliant with local guidelines
Recommends procedural improvements and training opportunities to management. Provides written audit reports to supervisor for review and approval
Reviews approved audit findings with physicians (individually and in a group setting) to discuss recommendations and improvement opportunities
Provides formal Pathway Adherence (Exception Documentation, Critical Elements)
Maintains the confidentiality of medical information contained in each record
Assist with other audits such as hospital visits, consultations, compliance, charge entry, reimbursement and others as assigned
Corrects discrepancies in Critical Elements, Exception Documentation

CQS Medical Auditor, Group Benefits Resume Examples & Samples

Deliver accurate and timely business assessment in support of Group Benefit strategic goals
Review and Evaluate claim files based on a holistic quality rating, driven by outcomes, accuracy, resolution, and customer service
Meet audit productivity goals, and through effective time management, planning and preparation, participate in focus reviews and special projects without sacrificing quality, detail orientation or calibration responsibilities
Effectively communicate observations, findings, file ratings, and quality driver with internal customers at all levels of the organization
Provide professionally written feedback on results and observations of the audit. Contribute to audit reports to illustrate strengths, opportunities and observed trends utilizing data to support the overall analysis, and ability to conduct root cause analysis
Provide constructive feedback to Regional Vice President and field management regarding Group Benefit audit results and observations
Be seen as a subject matter expert regarding; calibration, holistic rating factors, and the Claims Quality and Solutions Mission/Vision
Maintain a high degree of professionalism, credibility and integrity in the CQS audit program
Model personal integrity and drive the importance of ethics and compliance throughout the business
Continued personal career growth, and participation in personal development planning process
Adherence to The Hartford’s core values
Deliver Outcomes
Operate as a Team Player
Build Strong Partnerships
Strive for Excellence
Registered Nurse (RN) required and BSN and/or advanced degree (nursing or other) highly preferred
Functional level of expertise/SME in Behavioral Case Management, Rehabilitation Case Management, or Medical Management
CCM and/or CRC Designation required
3 to 5 years clinical experience
3+ years in Group Benefit Claim handling, quality control, or leadership. Specifically in at least two of the following areas is preferred: Short-Term disability, Long-Term Disability, and/or Life
Familiarity with short-term and long-term disability customer requirements for national, regional and priority accounts
Familiarity with Leave Management and Life product lines and clinical needs of claims within those Lines of Business
Strong clinical skills and medical knowledge, ability to use medical databases
Experience in case management of catastrophic cases preferred
Analytical skills - ability to integrate medical and claim issues to achieve optimal claim outcome
Experience accurately evaluating files from a holistic perspective preferred
Superior written and verbal communication and presentation skills
Self-motivated with a strong desire for excellence
Superior internal and external customer service skills
Self-starter and able to work in a virtual environment
Core Communication, Data, Customer Focus DNA Badges strongly preferred for current Claims Staff

Charge Auditor / Borgess Medical Center Resume Examples & Samples

Conducts audits of charges as compared to medical record documentation
Assists with responding to patients' inquiries concerning the accuracy of billed charges and charge descriptions
Assists with resolving third-party payor inquiries and billing disputes
Provides summary reports and analysis to hospital staff and management as required
Monitors daily reports and spreadsheets to ensure that charges are billed accurately and completely. Responsible for reconciliation and closing of charge batches
Communicates with appropriate parties regarding documentation that is needed for accurate charging and billing. Communicates charging issues to the appropriate department manager
Ensures audit conclusions are based on a complete understanding of the process, circumstances, and hospital standards
Timely and accurate data entry of assigned site's charges as needed
Minimum of one year of previous related experience and knowledge of surgical procedures and charging processes preferred

Medical Claims Auditor Resume Examples & Samples

Validates recoupment data provided by healthcare delivery contractors
Conducts research pertaining to ongoing and past claims audits for Contracting Officers and other DHA personnel as needed
Assists with the development of improper payment reports and provides meeting and analytical support
Conducts focused studies; drafts correspondence requesting clarification of TRICARE policy language
Conducts and interprets qualitative and quantitative analysis of data
Prepares documentation for healthcare contractor reviews
Bachelor’s degree from an accredited college in a related discipline, or equivalent experience/combined education, with 5 years of professional experience; or 3 years of professional experience with a related Master’s degree
Security Clearance: Public Trust (must be able to obtain and maintain)
Strong MS Office application skills (advanced knowledge of Excel and/or Access)
Data mining and analytical experience
Excellent organizational skills, communication and writing skills
Ability to produce complex reports and formalize conclusions and trends
Ability to manage multiple tasks and timelines
Claims auditing, claims processing, medical coding and/or billing experience, International Classification of Diseases Ninth Revision (ICD-9), ICD-10, TRICARE experience; statistical experience

Medical Claims Auditor Resume Examples & Samples

Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements. Applies knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client
Tracks, and follows-up on results and recoveries
Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team
Develops, maintains, and ensures adherence to multiple project schedules
Strong conceptual and analytical skills
Strong Project Management skills
Ability to develop, organize, and maintain project plans and agendas
Ability to effectively interface with clients
Working knowledge of Microsoft Suite of products (Excel, Word, Access)
Understanding or medical terminology and anatomy
Understanding of Medicaid required, Medicare and commercial experience a plus
In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers; and/or MSDRG, Revenue codes, and APCs
In depth knowledge of UB04 and medical (1500) claim formats and requirements
4+ years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required
Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc
Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred
Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience a plus preferred