Nurse Auditor Regulatory Compliance, Hybrid
University of Maryland Medical System
- Linthicum, MD
- Permanent
- Full-time
- Research applicable documentation and reimbursement policies to apply in the development of an audit plan for both scheduled and unscheduled UMMS Member Organization audits and investigations.
- Performs documentation and coding audits, reviewing medical records and charges to ensure compliance with CPT coding standards and the Centers for Medicare & Medicaid Services (CMS) conditions of coverage and guidelines.
- Conducts analysis of findings to identify trends/problems in billing and documentation.
- Drafts written reports that detail audit findings and recommendations to senior UMMS leadership, Department management/personnel, and/or other related business partners.
- Develops and administers coding and billing compliance training related to audit findings.
- Tracks and reports updates to coding and billing regulations.
- Works collaboratively with any department of UMMS and Member Organizations to research and resolve compliance investigations, including but not limited to, Member Organization Compliance Officers, Patient Financial Services, Reimbursement and Revenue Advisory Services, Health Information Management, Information Services and Technology, Case/Utilization Management, Quality, Pharmacy, Radiology, etc.
- Provides input to CCBEG management and operational leaders to assist in the creation of management action plans to resolve identified deficiencies.
- In collaboration with CCBEG management, performs activities specified in the Auditing and Monitoring Plan.
- Plans metrics from the Member Organization and developing reports for feedback to UMMS and the Member Organizations.
- Performs other duties as assigned.
- Bachelor of Science degree in Business Administration, Hospital Administration, Accounting, Nursing, or related discipline.
- Five years of experience in clinical setting analyzing data and performing reviews such as utilization management, quality assurance, charge capture, coding, billing and medical necessity to facilitate correct claims submission to federal and state payers required.
- Certifications in one or more of the following is preferred: a) American Academy of Professional Coders (AAPC) Certifications: Certified Professional Coder (CPC), Certified Outpatient Coding (COC), Certified Inpatient Coder (CIC), and/or Certified Professional Medical Auditor (CPMA). b) American Health Information Management Association (AHIMA) Certification: Certified Coding Specialist (CCS)
- Basic understanding of Medicare program and Maryland Medical Assistance program models and website navigation to facilitate accurate issue spotting and development of guidance to organization is required.
- Requires ability to read and understand a patient’s medical record as it relates to clinical documentation and diagnostic/procedural coding of the services provided.