UPMC is hiring a full-time Senior Medical Auditor to join their Department of Pediatrics team! This position will join our Pediatrics administrative team, which focuses on a team effort approach to solving complex challenges. This position is responsible for the complete education program for the 276 physicians and 213 APPs across the 20 specialties in the Department of Pediatrics. This role will also have the opportunity to interact with UPP Revenue Cycle on revenue enhancement initiatives and to help defend external coding audits when requested.

As the Senior Medical Auditor, you will provides technical expertise to review staff to ensure that all physicians, clinical, billing and coding staff are adhering to all guidelines for compliance as set forth by governmental, regulatory agencies and third party payors.

This position will work Monday through Friday, daylight hours, with no evenings, weekends, or holidays. We offer flexible scheduling for either 8-hour or 10-hour shifts. This is a fully remote position that will supoort the staff at Children's Hospital.

Responsibilities:

Consult with physicians and physician staff, as needed, on documentation issues, requirements for supervision of resident services and other regulatory issues as they arise.
Assist the Compliance Manager and Compliance Officer with quality assurance activites and with reporting the overall results (i.e., effectiveness assessments) of the regular, special and CERT+ audit programs.
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 duties and job responsibilities in a manner that coincides with the service management philosophy of the PSD including the demonstration of the basics of service excellence toward patients, visitors, staff, peers, physicians and other departments within the medical center.
Develop computer based audit spreadsheet that accurately depict all coding/documentation discrepancies, identifies the patient and provider of service, and provides a clear and concise statement of deficiencies per line item. All points should be thoroughly researched and references made readily available upon completion of audit for manager or practice discussion.
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 documentation and coding is compliant with Federal and State regulations. It is also the auditor's responsibility to note areas of determined lost revenue. All audit findings are the result of a thorough and complete review of all available documentation. It is the responsibility of the auditor to determine if all existing documentation has been reviewed. These audits will be performed according to guidelines set forth by regulatory agencies (CMS, OIG, DPW, etc.) and the National Committee of Quality Assurance. Concurrent audits may include the shadowing professional services to capture all billable services provided. Educational services may be provided simultaneously to the practice physician and practice staff as information in obtained. This responsibility includes a thorough knowledge of departmental chart and documentation flow, prior to the performance of a medical audit, to assure that documentation review encompasses all available records, as well as working closely with the Department Administrator, Chair, Practice Dir. to provide open communication lines during audit and educational processes.
Complete, review, and submit all audit spreadsheets and audit summaries to Compliance Manager as per audit schedule developed by Compliance Manager. Present draft audit results to the department/ractice staff and audited physicians and non-physician practitioners. This presentation must be well prepared and the auditor must have a thorough understanding of all issues cited in audit report and must present reference sources (with regulatory and rule-based exceprt language) within the report in support of audit findings.
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.
Ensure adherence to PSD compliance program and regulatory related recommendations. Bring unresolved issues to the attention of the Compliance Manager and the Compliance Officer.
Develop an audit report, to accompany audit spreadsheet, which captures overall percentage of services coded correctly and supported by documentation in the medical record (non-refundable events), 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 (refundable events), and other documentation, coding and billing concerns such as non-refundable modifier usage, ICD-9 diagnosis coding, date of service and etcetra. This audit summary report should conclude with recommendations to correct aforementioned areas of deficiencies including but not limited to departmental educational training sessions.
Attend department meetings and present educational update or discuss unique audit findings and recommendations as requested by the Compliance Manager. It is the Auditor's responsibility to seek out meetings that are specific to current auditor practice assignment and general continuing education.
Responsible for conducting and communication the results of special projects and all special audits as requested by the Compliance Manager or Compliance Officer.
Adhere to human resources policies and procedures.
Engage in communication as directed or required with PSD executive management regarding internal and external audits and the results thereof.
Directs Medical Auditor, Junior Medical Auditor and Auditor Analyst as required or as requested Compliance Manager or Compliance Officer. Reviews work produced by these staff and provides feedback to Compliance Manager.
Maintain professional affiliations and enhance professional growth and development to keep current on the latest trends in health care.
An associate's degree or comparable technical school diploma is required or equivalent years of experience.
6 years experience in coding and documentation of physician services is required.

In-depth knowledge of key revenue cycle processes, clinical documentation and financial operations. Strong interpersonal and organizational skills. Analytical and problem-solving skills. Ability to coordinate the work of others and communicate effectively with physicians and practice managers. Proficiency in MS Office. Advanced knowledge of managed care, capitation and commercial third party payor billing and reimbursement practices as well as current legal requirements. Excellent interpersonal, organizational, analytical and communication skills. Ability to effectively communicate with all levels of the organizations.

Licensure, Certifications, and Clearances:

Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT)
Act 31 Child Abuse Reporting with renewal
Act 33 with renewal
Act 34 with renewal
Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

UPMC has a Center for Engagement and Inclusions that is charged with executing leading-edge and next- generation diversity strategies to advance the organization’s diversity management capability and its national presence as a diversity leader. This includes having Employee Resources Groups, such as PRIDE Health or UPMC ENABLED (Empowering Abilities and Leveraging Difference) Network, that support the implementation of our diversity strategy.

Annual

Senior Medical Auditor - Pediatrics (Work from Home Opportunity)

Offer summary

Qualifications:

Key responsabilities:

Job description

Required profile

Experience

Hard Skills

Other Skills

Auditor Related jobs

Auditeur / Chef de projets certification (Dermatologie / Réanimation) H/F

Auditeur Financier Junior ESS - Le Havre - Décembre 2024 H/F

Auditor

Mitarbeiter Interne Revision (m/w/d)

Product Certification Auditor