Audit Professional

Job Title: Audit Professional

Reports to: Director - Internal Audit & Compliance Operations

Position Summary:

Under the direction of the Internal Audit department, the Audit Professional is responsible for ensuring regulatory compliance, identifying and mitigating risks, and conducting comprehensive audits using Artificial Intelligence (AI)-powered auditing tools. This role ensures the integrity and compliance of hospital billing processes by reviewing and analyzing claim data, medical records, and billing and payment information to ensure charges and reimbursement are supported according to federal and state program guidelines.

The position also collaborates with the Revenue Integrity department for recommendations with the development of strategies to optimize billing systems, mitigate risks, enforce internal controls, and ensure adherence to Luminis Health policies and procedures and regulatory requirements.

Essential Job Responsibilities:

1.    Monitor and analyze billing data for trends and inconsistencies, identifying areas of risk with opportunities for improvement utilizing AI-powered software (MDaudit), monitoring risk metrics, and providing feedback to department stakeholders with recommendations, as necessary.

2.    Ensure compliance with legal and regulatory billing requirements.

3.    Utilize AI-powered auditing tools to conduct audits and analyze large datasets, identify trends, and detect anomalies in healthcare operations to ensure compliance with CPT coding standards and the Centers for Medicare & Medicaid Services (CMS) conditions of coverage and guidelines.

4.    Conduct audits through AI-powered auditing tools by reviewing documentation in electronic medical record (EMR) platforms to validate the clinical documentation that supports the evaluation and management services, ancillary services, procedures, and diagnoses.

5.    Analyze audit findings, draft audit summary findings in written reports, provide detailed comments related to the audit findings, identify potential risks, and collaborate with relevant departments to make recommendations for corrective actions.

6.    Collaborate with the Revenue Integrity and Compliance departments to identify and resolve billing discrepancies and identified issues, review billing edits, identify root causes for edits, ensure integrated approaches to billing and audit functions, and recommend process enhancements.

7.    Participates in the Revenue Integrity/Compliance reviews on hospital billing including claims related to imaging, lab, mental health, and substance abuse to ensure optimal and compliant revenue cycle practices.

8.    Investigates Revenue Integrity-related compliance issues reported to Internal Audit.

9.    Supports special project initiatives, under the strategic direction of the Director of Internal Audit and Compliance Operations.

10. Maintain department audit standards, protocols, policies, and guidelines to ensure alignment with evolving regulatory frameworks.

11. Maintain up-to-date knowledge of industry regulations, guidelines, and best practices in auditing.

Qualifications:

• Bachelor’s degree in Healthcare Administration, Healthcare Auditing, Accounting, Compliance, or a related field.
• Five or more years in the healthcare industry with hospital coding, billing, auditing, compliance, and reimbursement experience that includes, charge capture, quality assurance, and medical necessity to facilitate correct claim submission to federal and state payers.
• Detail-oriented with strong critical thinking, organizational, and time management skills required to multitask effectively and adapt to changing priorities and responsibilities.
• Experience with billing systems and healthcare financial software.
• Strong written and verbal communication skills.  
• Strong knowledge of Federal regulations and guidelines as well as interactions as they relate to billing and coding compliance, including Medicare Conditions of Payment/Participation.

Preferred Skills:

• Must be proficient in Microsoft Office applications (Word, Excel, PowerPoint, and Outlook) and Electronic Medical Record platforms (Epic).
• Must be proficient in Billing/Coding Auditing AI-powered software technology (MDaudit).
• Experience and knowledge of Maryland All-Payer Model preferred.
• Healthcare Patient Financial Services, Revenue Integrity/Cycle, Payer experience preferred.

Licenses/Certifications: 

• Certified Professional Coder (CPC)
• Certified Professional Medical Auditor (CPMA)
• Certification in Healthcare Compliance (CHC) is required or willing to be obtained within the first year.
• Registered Health Information Technician (RHIT) are also desired.