Under the direction of the Department Leadership, this position is responsible for the coordination and completion of processes regarding Medicare audit request. The position also coordinates and communicates with various departments to ensure requests for documentation are responded to in a timely and complete manner. Agency status reports will include tracking and reconciliation of Medicare audit processes and outcomes. This position will also encompass electronically billing third party payers, maintains payer edit masters, produces management reports and controls flow of claims processing data in a consistent conscientious manner for services provided at AAMC.
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Provide education to AAMC and other providers regarding the Medicare audit programs and processes.
- Compile and communicate best practices for facility processes to respond to MAC & RAC audits and serve as a resource as AAMC implements processes to respond to chart requests and appeal determinations.
- Advise on resources necessary to effectively manage the MAC & RAC process and assist in identifying and procuring additional necessary resources.
- Promote the standardization of response to Medicare audits and internal billing system processes.
- Assist in evaluation of hospital efforts to review, respond to and appeal where appropriate, adverse Medicare determinations.
- Coordinate with all level appeals of Medicare determinations.
- Collect and prepare data on Medicare audit activities including the type of claims being reviewed by the MAC, RAC s and other Medicare auditors, the adverse determination rates with respect to each claim type, the status and success of all appeals.
- Work with clinical and others to modify the response and appeal process to continually enhance effectiveness.
- Report to management level on the impact of Medicare audit activities and the effectiveness of hospital and legal counsel responses.
- Monitor Medicare related resources and websites to ensure that up-to-date RAC strategies are in place.
- Bachelor's Degree or the equivalent in work experience.
- Must have a minimum of 5 years of increasing responsibility.
- Must have knowledge of Medicare, and third party payer rules and regulations.
- Minimum CRCS required
- This position is required to participate in continuing education activities and professional association certifications.
- The ideal candidate will have strong Medicare regulatory knowledge, working knowledge of Federal payer billing regulation, strong organizational skills and the ability to multi-task, well-developed communications skills, both oral and written, and working knowledge of personal computers including advanced understanding of spreadsheet software.
- Strong hospital financial, audit or billing compliance background with expertise in charge, documentation, billing and hospital workflow.
- Must have demonstrated written and verbal communication skills.
- Proficient in establishing and maintaining effective working relationships with both corporate and clinical departments.
Working Conditions, Equipment, Physical Demands:
There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands -
Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.