Auditor

• Audit execution & oversight by performing routine and ad hoc audits across the full revenue cycle process, including: Charge entry and charge capture accuracy, CPT, HCPCS, and ICD-10 coding compliance, Modifier usage, Workers’ compensation billing rules and state-specific fee schedules, Claim submission accuracy and clean claim rates, Payment posting and adjustment accuracy, AR follow-up effectiveness and denial resolution workflows
• Conduct pre-bill and post-bill audits to identify trends impacting reimbursement and compliance
• Denial & Revenue leakage analysis: Analyze denial trends across WC, Medicare, and commercial payers, Identify root causes of denials and recommend corrective actions, Quantify revenue impact from: Coding errors, Missed charges, Underpayments, Inefficient workflows
• Ensure adherence to: CMS guidelines and Medicare billing requirements, NCCI (CCI edits) and payer-specific edits, State Workers’ Compensation regulations, Documentation standards for pain management procedures
• Support internal and external audit readiness (RAC, MAC, payer audits).
• Reporting & KPI development through audit dashboard Maintain monthly & quarterly records of all RCM, clinical, and provider audit scores and training requirements
• Partner with all BHC teams to develop and deliver targeted education based on audit findings.
• Assist in creating and updating SOPs and workflows to reduce errors and improve efficiency
• Establish and maintain quality assurance programs across RCM functions
• Perform routine QA reviews of staff productivity and accuracy
• Recommend automation opportunities and system enhancements
• Assumes other responsibilities as appropriate to the position and organizational needs

RCM Auditor

• Conducts NCQA/URAC related UM and CM file reviews to ensure survey readiness
• Designs and implements quality improvement activities if goals are not met
• Analyzes data and prepares quality management reports in accordance with BH QM principles
• Participates in intra-departmental teams to improve sustainable member outcomes
• Assists in defining opportunities for improvement identified through analysis of trends
• Assists with coordinating improvement activities

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RCM Auditor

Behavioral Health Clinical Auditor