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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
The SIU Medical Records Auditor conducts comprehensive reviews (including Provider disputes and/or appeals) of medical records and documents supporting claims for medical and behavioral health care services. Manages and conducts specific medical billing audits to evaluate completeness of medical record documentation, identifies aberrant billing patterns and provides feedback to the Special Investigator team. The Incumbent provides investigative support to the Special Investigations Unit (SIU) related to issues and identifies potential overpayments and suspected health care fraud and abuse.
• Reviews and audits medical and behavioral health treatment records and analyzes inpatient and outpatient medical records using the most current published state and federal requirements related to the appropriate documentation requirements related to the billing of medical and behavioral health services (including, but may not be limited to, International Classification of Diseases (ICD-9/ ICD-10), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes according to federal and state statutory, regulatory and contractual requirements, AMA guidelines, other regulatory agencies and generally accepted coding practice, as may be applicable or appropriate).
• Verifies and validates authorization of services, written clinical documentation of services received through physical health services and behavioral health utilization management departments and information contained in the health care claims systems against claims, medical records and anomalies, abnormal billing patters and other indicators (e.g., services not rendered, up-coding, un-bundling, etc.) of suspected fraud and abuse.
• Coordinates individual work activities with SIU Manager and Investigators, develops and presents audit findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims and supports overpayment recovery during discussion with medical and behavioral health care providers.
• Coordinates payment issues with other areas and departments as required.
• Provides detailed written review of audit findings to management, plan representatives and State Regulatory Agencies, as may be appropriate or required.
• Must be able to use data analysis and extraction tools to evaluate transactions and identify potential billing errors or misstatements.
• Must be proficient with Medicare/Medicaid guidelines. Understanding of federal and state laws and regulations in medical reimbursement
• Understanding of anatomy and physiology, disease process, medical terminology and pharmacology.
• Works independently following established policies, procedures and practices.
• Consistently and positively communicates and collaborates with colleagues, supervisors, managers and customers both internal and external.
• Efficiently and independently plans time, meets deadlines, initiates and follows through on tasks.
• Listens respectfully and carefully, demonstrating flexibility in working with others in a team based environment.
• Performs all other duties as may be assigned.
- Bachelor's Degree and RN required.
- 3-5 years industry experience.
- Medical Record auditing experience required.
- Licensed Registered Nurse required, and Certified Professional Coder (CPC), or Certified Coding Specialist – Physician Based (CCS-P) or Certified Professional Medical Auditor (CPMA) preferred.
- Windows/Excel experience, case management documentation experience.