Revenue Cycle Auditor Professional

Auditor Specialist for Revenue Cycle Management (RCM) is responsible for overseeing auditing processes within medical billing and credentialing functions.

The ideal candidate will possess a strong background in healthcare administration, with experience in medical billing, credentialing, and RCM auditing. Key responsibilities include audit planning and execution, compliance and regulatory adherence, consulting and mentorship, performance analysis and reporting, follow-up and remediation, risk management and quality control, and continuous improvement.

• Audit Planning and Execution:
  - Develop and implement comprehensive audit plans for medical billing and credentialing processes.
  - Conduct regular audits on charge entries, payment postings, and claim submissions to ensure compliance with industry standards and company policies.
  - Review coding practices and billing procedures to ensure accuracy in documentation and claims.
• Compliance and Regulatory Adherence:
  - Ensure all billing and credentialing activities comply with relevant regulations (HIPAA, CMS guidelines, etc.).
  - Monitor for adherence to payer-specific billing rules and government regulations.
  - Stay updated on changes in healthcare laws and ensure the team is compliant.
• Consulting and Mentorship:
  - Serve as a role model and mentor to less experienced personnel on professional standards of performance.
  - Provide consulting services and lead independent audits and assessments to improve operations and manage risks related to complex technology and processes.
  - Mentor, train, and enhance the knowledge of Senior/Staff Auditors and other business area teams in auditing and RCM processes.
• Performance Analysis and Reporting:
  - Analyze audit findings to identify trends, issues, and areas for improvement in the RCM process.
  - Provide detailed reports on audit outcomes to stakeholders, outlining key performance indicators (KPIs), compliance issues, and recommendations for improvement.
  - Work closely with teams to resolve discrepancies and implement solutions to enhance revenue cycle efficiency.
• Follow-up and Remediation:
  - Follow up on past audit findings to ensure timely and adequate remediation.
  - Implement corrective action plans based on audit outcomes to enhance overall compliance and financial performance.
• Risk Management and Quality Control:
  - Identify and mitigate risks associated with the revenue cycle by ensuring strict compliance and best practices in billing and credentialing.
  - Conduct regular risk assessments and recommend strategies to minimize financial losses or compliance violations.
• Continuous Improvement:
  - Recommend process improvements to optimize the revenue cycle workflow and enhance operational efficiency.
  - Lead efforts to implement automation and advanced technology solutions for RCM auditing.
  - Track performance metrics and recommend actions for improved revenue capture and reduced denials.

• Education: Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field (required). Certification in Medical Billing/Coding, RCM, or relevant certifications (e.g., CPC, CPMA) preferred.
• Experience: 5+ years of experience in medical billing, credentialing, and RCM auditing, with leadership experience preferred. Minimum 5 years of full-time working experience in auditing or quality management in RCM or healthcare.
• Skills: Knowledge of ISO standards (ISO 9001, ISO 27001) and audit procedures. Advanced knowledge of Quality Methods, Risk Management, and relevant ISO certifications (ISO 14064-1 experience is an advantage). Proficiency in billing and auditing software tools (e.g., Epic, Cerner, Kareo, etc.). Excellent analytical, organizational, and mentoring skills. Strong communication and leadership abilities. Professional and mature attitude with the ability to work in fast-paced, dynamic environments.