Job Description

General Summary of Position
Assists in the MedStar Family Choice compliance program related to program integrity. Conducts provider audits to identify and address improper billing practices. We recruit, retain, and advance associates with diverse backgrounds skills and talents equitably at all levels.

Primary Duties and Responsibilities

• Analyzes current payment policies and makes recommendations to improve program integrity and organizational processes.
• Assists with and tracks responses to external government inquiries investigations data requests subpoenas and fair hearings. Responds to government requests for claims data/information.
• Prepares written audit reports and communicates the results to management. Initiates corrective action plans or continuous improvement plans identified through audits.
• Communicates compliance issues and findings identified through audits and reviews. Prepares written audit reports and communicates the results to management. Initiates corrective action plans or continuous improvement plans identified through audits.
• Coordinates monthly exclusion data base checks review and report findings.
• Completes assigned routine and selected audits all within assigned time frames. Ensures timely completion of risk assessments and related activities. Maintains or exceeds designated quality and production goals.
• Utilizes established process to track audits and follow-up claim reviews data requests including fraud analytics software audit case management system.
• Maintains confidentiality of all provider and member sensitive information reviewed during the auditing process.
• Participates in health plan and business unit meetings and serves on system wide committees as appropriate. Serves as a technical resource in researching and responding to compliance inquiries.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
• Performs routine and selected audits of member and employee data for possible fraud waste and abuse. Utilizes audit and monitoring tools to analyze and trend data to identify variances in claims billing in order to detect potential compliance issues.
• Performs concurrent and retrospective coding and documentation or clinical review audits of respective plan service areas including Behavioral Health services and other duties as assigned to detect potential compliance and/or fraud waste and abuse.
• Reports any inquiries concerning improper billing practices or reports of non-compliance to the Director of Medicaid Contract Oversight.
• Conducts telephonic member interviews as needed to verify services were received or to assist in other investigations.
• Analyzes and reports on claims data through a working knowledge of ICD-10 HCPCS and CPT coding guidelines state and federal regulations and various regulatory agency standards to identify trend and potential fraud waste and abuse.
• Conducts provider coding and documentation audits for specific provider types including behavioral health for MFC DC depending upon the health plan that this role supports (MFC MD or MFC DC).

Minimal Qualifications
Education

• High School Diploma or GED required
• Bachelor's degree preferred

Experience

• 4 years related experience required

Licenses and Certifications

• CCS-Certified Coding Specialist At least one coding credential required: Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Professional Coder (CPC) required

Knowledge Skills and Abilities

• Must possess excellent organizational skills including the ability to prioritize multiple tasks and perform them accurately and simultaneously.
• Ability to work with minimal supervision, guidance, and direction.
• Must be proficient with MS Office (Word, Excel, PowerPoint, and Outlook).
• Proficient knowledge of Medicaid, Medicare, and other third party payer requirements pertaining to documentation, coding, billing, and reimbursement.
• Proficient with performing coding and documentation reviews.
• Strong working knowledge of health care and provide billing regulations related to payer reimbursement policies and CPT/HCPCS coding guidelines.
• Excellent verbal and written communication skills.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Ability to establish and maintain positive and effective work relationships with members providers vendors and co-workers
• Demonstrated knowledge of and skill in data collection analysis and/or interpretation of provider claims data.
• Prior coding and documentation auditing experience is required in a provider or insurance environment.
• Auditing experience with specialized provider types such as behavioral health is preferred as identified by the health plan (MFC DC or MFC MD) that this role supports.

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