Inpatient Hospital Auditor II

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position is responsible for being the lead audits of hospital billing and coding practices and desk audits; forms development, profiling and tracking institutional audit trends. Designing audit protocols and special projects. Performs and finalizes multiple per diem, bill verification, DRG Validation (utilization review audits) and credit balance. Additionally provides guidance/instruction to various stakeholders on ICD10-CM/PCS, DRG assignment payment and auditing.

Responsibilities:

• Identifies and presents billing discrepancies found during audit and coordinates referral of improper claim payments through the appropriate channels.

• Identifies error trends as they relate to medical record and or billing documentation or misinterpretation of provider contract stipulations.

• Compiles statistics and other audit information to present to accounts, regulatory agencies, internal requesters.

• Reviews and updates audit processes with manager for purposes of keeping up with new innovations in clinical data review and company cost containment initiatives.

• Required to train new staff on department/audit procedures.

• Performs other special assignments as requested by manager.

• Demonstrates knowledge, understanding and conforms to laws, regulations and policies that pertain to the organizational units business.

Education/Experience:

• High School Diploma/GED required.

• Bachelor degree in Health Information Management preferred or relevant experience in lieu of degree.

• Requires a minimum of 3 years experience in a medical records department of an acute care hospital or other health care facility.

• Experience with DRG validation, ICD-10-CM/PCS training and education.

Additional licensing, certifications, registrations:

• Requires RHIT, RHIA or RN with CCS

• Preferred CCS, CCS-P or CCA certifications for those with RHIT or RHIA credentials.

Knowledge:

• Requires knowledge of medical terminology, detailed knowledge of anatomy & physiology, disease pathogenesis and treatment including procedural drug therapies, ancillary and diagnostic services.

• Requires knowledge of principles of utilization management.

• Requires knowledge of hospital structures and payment systems.

• Requires knowledge of centers of Medicare and Medicaid prospective payment system regulations.

• Prefer knowledge of ACCESS Software.

Skills and Abilities:

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.

• Must have strong PC skills experience with MICROSOFT office programs: excel, word and power point.

• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.

• Proven ability to ask probing questions and obtain thorough and relevant information.

• Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties.

• Must be detail oriented with strong organizational and data processing skills. Proven ability to follow detailed instructions is essential, along with proven problem solving skills.

• Proven analytical, research and problem solving skills a must.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

$77,900 - $1