Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

Scheduled Weekly Hours:

Position Overview

Claims Integrity Auditor

JOB CODE:30250

SUMMARY (BASIC PURPOSE OF THE JOB)

MINIMUM REQUIREMENTS

Education:Any healthcare technical license including Registered Nurse (RN), ARRT, or Registered Health Information Technician (RHIA/RHIT).

Experience:Three years of technical experience within a healthcare environment. Previous auditing, medical claims analysis, or Health Information Management experience in a healthcare setting preferred.

Other Credentials:

Knowledge and Skills:Demonstrates excellent verbal and written communication skills. Strong data analysis and problem-solving skills. Proficient in basic computer applications such as Word, Excel, and PowerPoint.

Special Training:Must possess thorough knowledge of medical terminology, anatomy, and physiology. Understanding of ICD-9/ICD-10 and CPT coding classifications.

Mental, Behavioral and Emotional Abilities:

Usual Work Day:8 Hours  

REPORTING RELATIONSHIPS

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Serves in a quality capacity verifying all charges on a patient account and is well-versed in all areas of the chart in order to determine appropriate charges.
• Understands patient billing requirements and applies this knowledge during chart review in order to verify that all appropriate charges have been added and that all inappropriate charges are removed. Performs compliance audits of records to ensure documentation is present to support all charges posted to the patient account.
• Collaborates directly with nursing units, ancillary departments, directors, and managers related to charging to ensure compliance with Federal and State regulations and continuous quality improvement.
• Reviews charts for documentation-related quality concerns including unsupported charges and services and misuse of departmental billing processes.
• Reports discrepancies to appropriate directors and managers and ensures that corrective action is taken in a timely manner.
• Performs chart review to identify if variation from quality billing exists and if so, determines the need for peer review. Identifies concerns and make recommendations for review to improve the process. Communicates findings as appropriate to staff/departments involved.
• Coordinates and performs preliminary review of charts selected by third party payers to ensure documentation is appropriate. Reviews data for external and internal requirements. Resolves issues as required.
• Reviews audit results from third payers and supplies additional information if in disagreement with findings. Keeps department apprised of status and relays up-to-date statuses as required.
• Manages loggings, filing, and storage of audited Medicare and Managed Medicare records. Ensures integrity of data and corrects errors as needed.
• Performs other duties as assigned and adapts to changing departmental demands.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include:

Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities

Continuous physical demands include: Sitting , Keyboard use/repetitive motion , Talk or Hear

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: N/A
 

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.