Senior Clinical Audit Specialist

Site: Mass General Brigham Incorporated

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

 

Job Summary

Reporting to the Central Audit Manager, the Senior Clinical Audit Specialist must have an understanding of medical terminology, coding, charge entry, and revenue cycle processes. The Senior Clinical Audit Specialist provides support for accurate, timely, and inclusive charge capture, coding assignments, billing functions, and revenue routing through evaluation and interpretation of payer updates, performance of record audits, presentation of staff education, and other related activities. The Senior Clinical Audit Specialist performs audits and identifies operational, financial, compliance, and other findings in order to make appropriate conclusions and determine next steps, best practices, and needed communications. This individual works collaboratively with the clinical audit team to identify charge system (including clinical system) weaknesses, recommends changes, provides education, and tracks utilization. This position is integral to the Central Audit team to assist in ensuring patient services are accurately charged, appropriately coded, supported by clinical documentation, and that the related revenue is recorded in the proper department.


The Senior Clinical Audit Specialist must approach problem-solving challenges independently, under limited supervision from the Central Audit Manager or other more senior team members, have a strong attention to detail, and enjoy working in a fast-paced, collaborative team-based environment. The RI team is responsible for department charge audits and data analytics, as well as investigating and resolving charging and coding issues, and staying abreast of all changes related to billing/coding compliance. The Senior Clinical Audit Specialist coordinates processes between clinical operations and revenue cycle departments, ensuring that the accounts audited reflect proper documentation, charge capture, coding, and billing to support proper payment. The Senior Clinical Audit Specialist also confirms that the charges are routed to the appropriate department/cost center. Audits will be assigned for encounters falling within the IP, OP, and ED areas, for both hospital and professional services, with the expectation that this person understands hospitals' payer contracts and reimbursement methodologies. This person will assist the RI team with running revenue reports daily and will explore possibilities of revenue leakage in any targeted areas identified through the audit process.

 

Qualifications

Education
Bachelor's Degree in Health Information required or Bachelor's Degree Related Field of Study

Licenses and Credentials

• Applicable professional certification through AHIMA (RHIA, RHIT, CCA) or AAPC (CPC-A, CPC, COC-A, COC) or other coding certification required.

Experience
Healthcare auditing or financial auditing experience 1-2 years required

Principal Duties and Responsibilities

• Perform audits, meet with departmental leadership to review findings, documentation standards, and recommendations for improvement.  Targeted populations are identified through random sampling, focused quarterly reviews, issues identified in collaboration with various MGB personnel, and rotation/selection of specific clinical areas.
• Audits include review of selected medical records documentation to determine accuracy of coding assignments, billing compliance, medical necessity, and when appropriate, collaborate with hospital HIM and revenue cycle departments to identify physician and clinic practices that require improved documentation.
• Analyzes charge capture audit reports to verify that appropriate charges have been posted to patient accounts according to diagnosis and related procedure codes and that revenue has been routed/recorded in the appropriate department/cost center.
• Performs ancillary service quality assurance reviews and departmental audits, and meets with the department managers and staff to instruct and inform on documentation findings to increase accuracy; recommends solutions to improve charge capture accuracy.
• Provides feedback to providers regarding missing, incomplete, unspecific, unclear, or conflicting documentation. 
• Provides coding, documentation, and compliance guidance as requested.
• Ass