Quality Assurance Clinical-Billing Auditor-QA535206

JOB SUMMARY

The Clinical and Billing Auditor is responsible for the oversight and management of auditing and monitoring activities across the organization. Using a unique combination of clinical expertise and billing knowledge, this role monitors and improves the quality of clinical and financial documentation related to patient services. The auditor compares clinical and financial records to ensure that provided documentation supports the charges listed, helping to mitigate errors, prevent fraud, and optimize appropriate reimbursement.

ESSENTIAL JOB FUNCTIONS: List all essential job duties. (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.)

• Reviewing Documentation: Audit clinical documentation, treatment plans, and progress notes as well as utilization reviews to ensure accuracy, completeness, and compliance with billing requirements, regulatory & quality standards, and diagnostic criteria for ICL outpatient programs.
• Monitoring Program Effectiveness: Evaluate the effectiveness of mental health and intellectual disabilities programs in achieving desired outcomes, such as symptom reduction, functional improvement, and enhanced quality of life for individuals served. Identify opportunities for program enhancement based on audit findings and performance metrics.
• Assessing Clinical Quality: Evaluate the quality and appropriateness of clinical care provided to individuals with mental health conditions. including assessment, diagnosis, treatment planning, and therapeutic interventions. Ensure adherence to evidence-based practices and ethical standards.
• Identifying Training Needs: Identify training needs and provide education and support to clinicians, staff, and providers on topics related to billing compliance, documentation standards, diagnostic criteria, treatment modalities, and best practices in ICL outpatient programs.
• Collaborating with Multidisciplinary Teams: Participation in managing clinical risks in the agency by participating in Incident Review Committee Meetings, High Risk Meeting, and Sentinel Reviews, Psychiatric Medical At-Risk Case conference. Work collaboratively with clinical teams, including psychiatrists, psychologists, social workers, therapists, and case managers, to ensure coordinated and integrated care for the clients with ICL outpatient programs and intellectual disabilities. Participation in managing clinical risks in the agency by participating.
• Risk Management & Compliance Oversight: Identify high risk areas for fraud, waste and abuse. Escalate significant compliance concerns. Support organizational readiness for external audits, payer investigations.
• Rate & Billing Accuracy Validation: Ensure correct application of fee schedules and rate codes. CPT/HCPCS codes (where applicable. Cross-check billed services against Program type, staff credentials, service duration, and monitor adherence to payer-specific billing requirements.
• Regulatory Recovery and Risk Mitigation: Consult with division administrators to develop and execute quality improvement plans, including plans of corrective action (POCAs) for certification visits and internal agency audit reports. 
• Operational Integration: Participate in program planning projects and meetings to provide inputs on development of quality control and program evaluation elements; and conduct or participate in management meetings with service-delivery staff to establish, delineate, and review program organizational policies, to coordinate functions and operations between departments , and establish responsibilities and procedures for attaining objectives and assist with the implementation of new programs.
• Staying Informed: Stay updated on changes in healthcare regulations, billing requirements, reimbursement policies, and quality assurance standards relevant to mental health and intellectual disabilities services. Maintain knowledge of emerging trends, research findings, and best practices in the field.
• Perform other related duties as assigned.

ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Committed to the active promotion of ICL values and goals.
• Demonstrated mastery of ICD-10-CM, CPT, and HCPCS codes.
• Proficiency in Electronic Health Records (EHR) systems and advanced Microsoft Excel skills for data analysis.
• A solid understanding of HIPAA, Medicaid/Medicare billing rules, and documentation standards.
• Knowledge of relevant industry regulations and compliance standards to ensure adherence to legal and ethical guidelines.
• Ability to collaborate effectively with individuals at all levels of the organization.
• Ability to educate staff on compliance issues and quality improvement continuous measures.
• Strong organizational skills to manage multiple audits, prioritize tasks, and meet deadlines.
• Excellent verbal and written communication skills.
• Ability to identify risks related to client safety, compliance, and quality of care.
• Ability to analyze information objectively and form a reasoned judgment.
• A keen eye for detail for identifying inconsistencies, errors, and areas of non-compliance.
• Ability to make sound judgments and decisions based on evidence and analysis.
• Ability to adapt and willing to learn new techniques and technologies.

QUALIFICATIONS AND EXPERIENCE:

Master’s degree in social work, or Psychology, or related field plus 2 years’ experience in a clinical or human services environment conducting assessments or evaluations, performing quality assurance work, or managing programs. Certification: CPMA (Certified Professional Medical Auditor) or CHC (Certified in Healthcare Compliance) or CPB (Certified Professional Biller) designation strongly preferred.

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