Medical Auditor Job Description
Medical auditor
provides technical support to medical providers, as appropriate, regarding coding compliance documentation, regulatory provisions and third-party payer requirements.
Medical Auditor Duties & Responsibilities
To write an effective medical auditor job description, begin by listing detailed duties, responsibilities and expectations. We have included medical auditor job description templates that you can modify and use.
Sample responsibilities for this position include:
Reviewing require data analysis and research within the the organization's data systems
Auditing CMS & or Commercial Insurance billing for diagnosis data collected from physician and hospital medical records (collection and analysis coding and reimbursement guidelines)
Reviewing and researching medical records to determine the accuracy of coding, billing and supporting clinical documentation either in an health care facility or in the organization's assigned office
Assisting pursuit staff as needed in requesting records
Maintaining current knowledge of requirements and guidance required in the performance of audit duties, including but not limited to ICD9, CMS
Reviewing medical records that have been reviewed and coded by the coding vendor
Adhere to measured productivity requirements and module testing
Share departmental responsibilities as assigned
Audit CMS and/or Commercial Insurance billing for diagnosis data collected from physician and hospital medical records
Review and research medical records to determine the accuracy of coding, billing and supporting clinical documentation
Medical Auditor Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Medical Auditor
List any licenses or certifications required by the position: SSC, SGS, CPC, AHIMA, AAPC, CRC, COC, CIC, CCS, RHIT
Education for Medical Auditor
Typically a job would require a certain level of education.
Employers hiring for the medical auditor job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Technology, Chemistry, Biophysics, Bioengineering, Biochemistry, Physiology, Biology, Medicine, Physics
Skills for Medical Auditor
Desired skills for medical auditor include:
HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information
Promoting confidentiality and using discretion when handling patient information
Current and changing regulatory requirements related to coding and compliance
Physician billing process and medical record audit process
Medicare
Departmental chart and documentation flow
Medicaid and local third party carrier regulations
Medical terminology
Prior to the performance of a medical audit
To assure that documentation review encompasses all available records
Desired experience for medical auditor includes:
Work under the supervision of internal staff and designated lead in order to achieve goals and keep the project moving
Reviews require data analysis and research within data systems
Assist pursuit staff as needed in requesting records
Assist the team with research and documentation
Maintain current knowledge of requirements and guidance required in the performance of audit duties
Review medical records that have been reviewed and coded by the coding vendor
Medical Auditor Examples
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Medical Auditor Job Description
Job Description Example
Our company is looking to fill the role of medical auditor. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical auditor
- Coordinate auditing outcomes and system maintenance with the Sr
- Review radiology medical record outpatient encounters, medical record documentation, and coding to ensure compliance with applicable coding, billing and federal and state regulatory requirements
- Use our Radiology Information System (RIS) and medical billing system to review medical records
- Perform compliance-related projects based on coding, billing and regulatory guidelines
- Independently, evaluate the scope of each day's work and appropriately manage and prioritize your time to meet deadlines
- Support the compliance department by participating, completing, and/or leading projects and tasks, as assigned
- Responsible for creating and conducting QA audits and results on all new hires, new clients, audits of tenured colleagues on new accounts
- Perform other duties as needed in the remote coding area
- Conduct post-audit compliance training sessions for PSD physicians and non-physician practitioners as audit results dictate
- Perform quality management system audits against European Directives with particular focus on the DACH and German speaking customers
Qualifications for medical auditor
- Experience with codes related to medical and dental claims (i.e., ICD, CPT, CDT, HCPCS, Revenue codes, ) and identification of coding inconsistencies
- Auditor will have the ability to work remotely from any geographical location within the United States
- 3+ years coding of experience including inpatient and/or outpatient coding skills ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
- 3+ years coding of experience including inpatient and outpatient coding skills ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
- BS/BA with a minimum of five years of related work experience including but not limited to claims
- Must understand Behavioral Health Claims
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Medical Auditor Job Description
Job Description Example
Our innovative and growing company is looking for a medical auditor. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for medical auditor
- Subject to training and qualification milestones
- Support Competent Authority (MHRA) activities on as needed basis MHRA witnessed audits of UL
- Provide support to customers inquiries, meetings and other customer events
- Participate in regular training on ISO standards, applicable regulations and associated guidance
- Frequent European and international travel is required
- Provide support to field auditors when requested – prepping reports, QA on IT reporting and audit reports, sample selection
- Provide professionally written feedback on results and observations of the audit
- Be seen as a subject matter expert regarding
- Monitors daily reports and spreadsheets to ensure that charges are billed accurately and completely
- Communicates with appropriate parties regarding documentation that is needed for accurate charging and billing
Qualifications for medical auditor
- Candidates must have prior experience with research and either HEDIS measures or auditing data submitted as claims
- Candidates must have computer skills and analysis capabilities in order to navigate CPT4 code and ICD9 and ICD10 DX based on
- Candidates must have an understanding of codes for services based on diagnosis and procedure
- Candidates must have basic Excel skills and must have the ability to type 30-40 WPM
- 5-10 Years Clinical/Auditing Experience
- Diverse acute and post-acute care clinical nursing experience
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Medical Auditor Job Description
Job Description Example
Our innovative and growing company is hiring for a medical auditor. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for medical auditor
- Conducts focused studies
- Provides quarterly quality reviews of Utilization Management staff determinations and regulatory compliance and correct application of Milliman guidelines
- Audits the work of staff to improve their adherence to clinical guidelines in the Utilization Review process
- Manages the internal review process to document internal inter-rater reliability and provides independent quality assurance within the department
- Provides monthly quality reviews of UM nurse determinations in Facets Prospective UM
- Keeps up-to-date on State and Federal regulation
- Attends workshops, reviews professional publications, and participates in professional societies
- Skilled experience with Milliman and Interqual Guidelines, Facets
- Skilled in the application of Clinical Guidelines
- Skilled background in case management, disease management, discharge planning, performance improvement and data analysis
Qualifications for medical auditor
- First degree, or equivalent vocational qualifications - BA/BSc, HND, Chartered Engineer, diploma etc in life sciences with microbiological aspect/modules or a microbiology degree
- Professional or internal certification(s) may be required, depending on job assignment
- Must possess technical and professionals skills in financial analysis interpersonal skills
- Demonstrate experience conducting Medical Record audits and ability to interpret and apply Federal and State regulations, coding and billing requirements
- Comprehensive knowledge of medical diagnostic and procedural terminology is required
- Demonstrated ability to constructively and sensitively provide feedback to providers and medical center leadership regarding federal and state coding, medical documentation and compliance guidelines, audit results and risk areas
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Medical Auditor Job Description
Job Description Example
Our growing company is hiring for a medical auditor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for medical auditor
- Develop an audit summary report, to accompany audit spreadsheet which captures overall percentage of services coded correctly and supported by documentation in the medical record, services determined to be at risk due to incorrect selection of code type, over-coding, under-coding, coding not supported by documentation in the medical record, misuse or absence of modifiers, bundling and other coding violations, and specific documentation concerns such as trending, pattern or recipe coding
- Develop computer based audit spreadsheet or provide all audit information to Audit Analyst to develop a computer based audit spreadsheet, that addresses sufficient areas to accurately reflect any coding/documentation discrepancies, identifies the patient and provider of service, and provides a clear and concise statement of deficiencies per line item
- Educational services may be provided simultaneously to the practice physician and practice staff as information in obtained
- It is the researched information to staff, providing on-going educational updates
- It is the Auditor's responsibility to seek out meetings that are specific to current auditor practice assignment and prepare to present or offer information that may be appropriate during said meeting
- Perform duties and job responsibilities in a manner that coincides with the service management philosophy of the UPP including the demonstration of the basics of service excellence toward patients, visitors, staff, peers, physicians and other departments within the medical center
- Present final audit results to Department staff and faculty
- Responsible for conducting special projects, which may include audits, as necessary
- Special projects may require spreadsheet development reports that summarize outcome of special projects
- These audits may be performed in conjunction with the Billing Department
Qualifications for medical auditor
- Demonstrated ability to review analytical data and audit findings to identify coding trends and other risk areas
- Demonstrated ability to develop data requirements and work with analytical groups to extract, organize and analyze coded data
- Ten years coding and auditing experience including inpatient and outpatient coding skills ambulatory surgery, APC, emergency room, evaluation and management, auditing, report-writing expertise, required
- 3+ years in Group Benefit Claim handling, quality control, or leadership
- Assist clients with questions relevant to the audit and/or certification
- Provide management with updates on status of work, initiatives, and projects
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Medical Auditor Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of medical auditor. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical auditor
- These training sessions will include, but are not limited to, on-going educational updates as required and communication of new guidelines as they develop and/or issues by regulatory agencies
- This audit summary report should conclude with recommendations to correct aforementioned areas of deficiencies including but not limited to departmental educational training sessions
- This concurrent audit may include the shadowing professional services to capture all billable services provided
- Review and evaluate primary care medical charts for coding accuracy and correct coding errors as needed
- Review existing billable reports, claim hold queues and any other data available to ensure that coding is accurate
- Communicate and work with appropriate staff to correct coding errors in the customized billing system when it affects FQHC and Fee for Service medical coding
- Ensure assignment of provider identifiers with outside payors in an efficient manner, thus enabling streamlined billing, payment and reconciliation of patient accounts
- Communicate electronic health record functionality issues with their leader or the IT Helpdesk
- Provides feedback to enhance quality service through identifying process deviations and training needs
- Responsible for auditing all claims exceeding the processors draft limit and performing random audits on each processor as required
Qualifications for medical auditor
- Knowledge of outpatient coding practices at both the clinical and inpatient settings
- Required knowledge of compliance and regulatory requirements including outpatient CMS regulations
- Ability to read and interpret medical data
- Travel will include overnight/multiple days, to various worksites and client
- Certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS)
- Minimum of 5 years coding and audit/chart review experience is preferred