The posting
Job Summary :
The Revenue Integrity Auditor identifies billing and coding discrepancies, potential compliance violations, revenue leakage, overpayments, underpayments, documentation deficiencies, and operational control weaknesses. The role develops audit findings, recommends corrective and preventive actions, monitors remediation efforts, and collaborates with Revenue Cycle, Health Information Management (HIM), Coding, Patient Financial Services, Clinical Documentation Integrity (CDI), Compliance, Privacy, and Information Security teams to promote sustainable compliance and financial integrity.
Job Description
Essential Responsibilities:
- Comprehensive Revenue Integrity Auditing:Conduct routine, focused, retrospective, and risk-based audits across the healthcare revenue cycle, including patient registration, eligibility, authorization, charge capture, coding, billing, claims submission, payment posting, and account adjustments. Perform end-to-end account audits to validate the accuracy and completeness of patient encounters, charges, supporting documentation, claim submission, reimbursement, and financial transactions. Evaluate compliance with internal policies, standard operating procedures, payer contracts, reimbursement methodologies, and applicable regulatory requirements. Identify revenue leakage, missed charges, duplicate charges, inappropriate write-offs, unsubstantiated adjustments, billing errors, and reimbursement variances. Assess the effectiveness of revenue cycle controls and recommend improvements to reduce compliance risk and prevent recurring errors. Develop and maintain audit plans, sampling methodologies, audit tools, workpapers, and supporting documentation.
- Medical Coding, Clinical Documentation, Billing and Claims Compliance:Audit ICD-10-CM/PCS, CPT, HCPCS Level II, and other applicable coding for accuracy, completeness, specificity, and consistency with supporting medical record documentation. Evaluate appropriate assignment of diagnoses, procedures, modifiers, units of service, place of service, and other claim elements, as applicable. Review compliance with official coding guidelines, National Correct Coding Initiative (NCCI) edits, medically unlikely edits, and payer-specific billing policies. Assess medical necessity, documentation sufficiency, and the appropriateness of billed services in accordance with applicable coverage and reimbursement requirements. Identify potential upcoding, undercoding, unbundling, duplicate billing, unsupported services, and other coding or billing practices that may create compliance exposure. Collaborate with coding and CDI teams to clarify documentation deficiencies, validate audit findings, and support education and corrective action. Provide recommendations for coding corrections, claim adjustments, and other appropriate remediation in accordance with organizational policy and applicable law. Review outpatient, inpatient, and facility claims, as applicable, for accurate charge reporting, coding, billing, and reimbursement. Validate compliance with Medicare, Medicaid, commercial payer, and other applicable billing requirements. Evaluate claim edits, denials, rebilling practices, late charges, and adjustments for accuracy and compliance. Identify patterns involving inappropriate reimbursement, unsupported charges, missed revenue opportunities, and preventable claim denials. Escalate potential improper payments, suspected fraud, waste, abuse, and significant billing compliance concerns through established reporting channels.
- HIPAA Privacy, Regulatory Compliance, Risk Assessment, and Confidentiality Auditing:Assess revenue cycle workflows for compliance with applicable HIPAA Privacy Rule and Security Rule requirements and organizational privacy and security policies. Evaluate appropriate access to PHI, minimum-necessary practices where applicable, secure handling of medical records, and appropriate use and disclosure of information during billing, coding, auditing, and reimbursement activities. Review audit processes involving electronic health records, billing systems, claim attachments, payer communications, and other systems containing PHI. Identify potential privacy risks, inappropriate access, unauthorized disclosures, insecure information transmission, and deficiencies in the handling or retention of sensitive information. Verify that audit documentation, supporting evidence, and reports containing PHI are accessed, stored, transmitted, and retained in accordance with applicable requirements and organizational procedures. Coordinate suspected privacy or security incidents with the Privacy Officer, Information Security, and Compliance teams for appropriate investigation and follow-up. Support privacy awareness and compliance education for revenue cycle personnel. Maintain working knowledge of applicable CMS regulations, Medicare and Medicaid billing requirements, HIPAA, the False Claims Act, payer policies, and other relevant federal and state requirements. Conduct risk assessments to identify high-risk billing practices, regulatory vulnerabilities, control deficiencies, and emerging compliance trends. Evaluate adherence to organizational compliance policies, applicable coding standards, documentation requirements, and established internal controls. Support compliance investigations, external audit requests, payer audits, governmental reviews, and other regulatory inquiries as assigned. Prepare accurate, objective, and defensible audit workpapers documenting scope, methodology, evidence, findings, risk levels, and conclusions. Escalate significant findings promptly to appropriate leadership and compliance personnel.
- Continuous Improvement:Prepare comprehensive audit reports summarizing findings, root causes, financial impact where quantifiable, compliance exposure, and recommended corrective actions. Partner with operational leaders to develop corrective action plans, assign responsibilities, establish target completion dates, and define measurable outcomes. Conduct follow-up audits and validation testing to confirm that corrective actions have been implemented and are effective. Monitor recurring errors, audit trends, denial patterns, coding discrepancies, and other key performance indicators. Develop and deliver targeted education to address identified knowledge gaps and recurring compliance issues. Recommend process improvements, system edits, automated controls, and preventive measures to strengthen revenue integrity. Maintain appropriate confidentiality, independence, and objectivity throughout the audit process.
- I. Knowledge, Skills and Abilities: Ability to conduct comprehensive, objective, and risk-based audits. Working knowledge of HIPPA privacy and security requirements and appropriate PHI handling. Strong analytical, investigative, critical-thinking, and problem-solving skills. Ability to interpret regulations, payer policies, medical records, financial data, and audit evidence. Proficiency with electronic health records, billing platforms, spreadsheets, reporting tools, and audit tracking systems. Excellent written and verbal communication skills, including the ability to present findings to operational and executive leadership. Ability to maintain confidentiality, exercise sound judgment, and handle sensitive compliance matters professionally. Strong organizational skills and the ability to manage multiple audits, deadlines, and competing priorities. Ability to work with associates to promote education, excellence, and job satisfaction among employees. Ability to lead, promote long-term employment and implement new procedures. Promote teamwork within the department and achieve overall department goals. Interact with all associates, physicians, and general public appropriately. Maintain emotional stability and calm disposition. Possess a high level of loyalty, reliability, tactfulness, honesty, and discreetness. Able to handle confidential information in a professional manner. Adaptable to changes in work schedules and interruptions in work. Strong Knowledge of healthcare revenue cycle operations, billing practices, and coding guidelines.
- II. Education and Experience Required:Bachelors required in Business, Finance, Nursing, or Health Information Management. Registered RN with current RN license and or a hospital Inpatient coder with a CCS certification preferred. 5 + years of revenue cycle experience within integrated healthcare system, preferably within hospital revenue integrity department. RHI/RHIT/CCS/BSH license required Experience evaluating healthcare regulatory requirements, payer billing policies, and internal controls. Familiarity with HIPAA privacy and security requirements and the handling of PHI. Experience preparing audit reports, appeal letters, and identifying root causes.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the associate for this job. Duties, responsibilities and activities may change at any time with or without notice.
Work Shift :
1st Shift (United States of America)
Scheduled Weekly Hours :
40
