Bay Area Hospital

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Medical Auditor & Appeals Specialist - Patient Accounting - FT - DAYS

at Bay Area Hospital

Posted: 9/18/2019
Job Status: Full Time
Job Reference #: 90491621363
Keywords: billing, compliance

Job Description

Full-Time Position (80 Hours Per Pay Period)

Shift: 0800-1700        Days: Varied

Wages Based Upon Experience

CLOSING DATE: Open Until Filled



Support the organization’s mission, vision and values by adhering to the behavioral standards of Bay Area Hospital.  Comply with all laws and regulations affecting Bay Area Hospital.  Be familiar with and adhere to the Code of Conduct and support the Bay Area Hospital Compliance Program.  Effective communication skills and the ability to work effectively with people from various backgrounds are critical.


Audits records to ensure that documentation matches charges and reviews denials and acts as liaison with vendor on outsourced appeals.


(Essential job requirements listed in bold)

•Audits revenue cycle with specific focus on documentation, charge capture, medical appropriateness, regulatory compliance, billing accuracy, and compliance with hospital policy
•Audits areas of concern based on direction of executive leadership and compliance committee with periodic reports  
•Serves as the point person for payer and/or Recovery Audit Contractors (RAC) focusing on defending hospital claims for reimbursement 
•Conducts regular audits and coordinates ongoing monitoring of coding and documentation accuracy and provides feedback and focused educational programs on the results  to affected staff, physicians and compliance officer 
•Assist PFS II staff with appeals on denied claims
•Reviews denials to determine when to outsource and acts as a liaison with outsourced vendors

•Works with third party payers to ensure accurate payment and resolution of billing issues
•Maintains RAC, CMS, TPE, and ADHOC log, database, produces reports requested and assists with appeals associated with RAC
•Works with department managers on validation of documentation practices and charge capture 
•Initiates corrective action to ensure resolution of problem areas identified during an internal investigation or auditing/monitoring activity  
•Serves on the compliance committee
•Provides analysis of audits and written reports as assigned 
•Resource for revenue cycle staff

Skill / Requirements

(Essential job requirements listed in bold)

•Demonstrates the ability to use a personal computer and various software programs applicable to the position  
•Exhibits the ability to deal effectively interdepartmentally, with the public, vendors, and governmental agencies
•Maintains regular, consistent and punctual attendance at the assigned job location

•Demonstrates the ability to operate applicable office equipment
•Exhibits the ability to maintain confidentiality, think and act independently with minimal supervision

(Essential job requirements listed in bold)

•Registered Nurse (RN)  or equivalent experience
•Bachelor’s Degree in Nursing (BSN) preferred
•Required to have or is actively pursuing at least one of the following certifications
•Certified Medical Auditor (CMAS)
•Certified Coding Specialist (CCS)
•Certified Professional Coder by the American Academy of Professional Coders (AAPC)
•Certified Professional Healthcare Management (CPHM)

(Essential job requirements listed in bold)

•5 years’ experience in an acute care hospital auditing, coding, billing, or related field such as health-care administration
•Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing
•Experience with physician & other clinician education/feedback on documentation improvement

•Experience with healthcare billing, coding and revenue cycle principles and regulations preferred


Union Affiliation:  None

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position.  They are not intended to be an exhaustive list of all duties, responsibilities and job skills required. 

Physical/Mental/Environmental Requirements

• Requires extensive sitting with periodic standing and walking

• May be required to lift up to 20 pounds

• Requires significant use of personal computer, phone and general office equipment

• Needs adequate visual acuity, ability to grasp and handle objects

• Needs ability to communicate effectively through reading, writing, and speaking in person or telephone

• May require off-site travel