Sr. Clinical Audit Specialist

Site: Mass General Brigham Incorporated Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Reporting to the Central Audit Manager, the Senior Clinical Audit Specialist must have an understanding of medical terminology, coding, charge entry, and revenue cycle processes. The Senior Clinical Audit Specialist provides support for accurate, timely, and inclusive charge capture, coding assignments, billing functions, and revenue routing through evaluation and interpretation of payer updates, performance of record audits, presentation of staff education, and other related activities. The Senior Clinical Audit Specialist performs audits and identifies operational, financial, compliance, and other findings in order to make appropriate conclusions and determine next steps, best practices, and needed communications. This individual works collaboratively with the clinical audit team to identify charge system (including clinical system) weaknesses, recommends changes, provides education, and tracks utilization. This position is integral to the Central Audit team to assist in ensuring patient services are accurately charged, appropriately coded, supported by clinical documentation, and that the related revenue is recorded in the proper department. The Senior Clinical Audit Specialist must approach problem-solving challenges independently, under limited supervision from the Central Audit Manager or other more senior team members, have a strong attention to detail, and enjoy working in a fast-paced, collaborative team-based environment. The RI team is responsible for department charge audits and data analytics, as well as investigating and resolving charging and coding issues, and staying abreast of all changes related to billing/coding compliance. The Senior Clinical Audit Specialist coordinates processes between clinical operations and revenue cycle departments, ensuring that the accounts audited reflect proper documentation, charge capture, coding, and billing to support proper payment. The Senior Clinical Audit Specialist also confirms that the charges are routed to the appropriate department/cost center. Audits will be assigned for encounters falling within the IP, OP, and ED areas, for both hospital and professional services, with the expectation that this person understands hospitals' payer contracts and reimbursement methodologies. This person will assist the RI team with running revenue reports daily and will explore possibilities of revenue leakage in any targeted areas identified through the audit process. Qualifications Bachelor's Degree in Health Information required or Bachelor's Degree Related Field of Study Licenses and Credentials Applicable professional certification through AHIMA (RHIA, RHIT, CCA) or AAPC (CPC-A, CPC, COC-A, COC) or other coding certification required. Experience Healthcare auditing or financial auditing experience 3-5 years required Principal Duties and Responsibilities - Perform audits, meet with departmental leadership to review findings, documentation standards, and recommendations for improvement. Targeted populations are identified through random sampling, focused quarterly reviews, issues identified in collaboration with various MGB personnel, and rotation/selection of specific clinical areas. - Audits include review of selected medical records documentation to determine accuracy of coding assignments, billing compliance, medical necessity, and when appropriate, collaborate with hospital HIM and revenue cycle departments to identify physician and clinic practices that require improved documentation. - Analyzes charge capture audit reports to verify that appropriate charges have been posted to patient accounts according to diagnosis and related procedure codes and that revenue has been routed/recorded in the appropriate department/cost center. - Performs ancillary service quality assurance reviews and departmental audits, and meets with the department managers and staff to instruct and inform on documentation findings to increase accuracy; recommends solutions to improve charge capture accuracy. - Provides feedback to providers regarding missing, incomplete, unspecific, unclear, or conflicting documentation. - Provides coding, documentation, and compliance guidance as requested. - Assists and directly provides training in group settings as well as one-on-one. - Presents in-services to nursing, physician, and clerical personnel regarding processes, updates, and reviews relating to audit findings and/or regulatory compliance. - Coordinates with Clinical Nurse Auditor(s), Clinical Audit Specialist(s), or RI Analyst(s) to complete various inquiries by departments to ensure accurate and timely responses. - Maintains current knowledge of the Charge Description Master, clinical charging procedures, and related systems for the production of a bill/claim. - Remains current with regulation changes and related operational processes by attending coding conferences, workshops, and in-house sessions for updated coding information. - Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives. - Participates in MGB internal projects - Other duties as assigned Knowledge, Skills, and Abilities - Strong oral and written communication skills. - Strong problem-solving and critical thinking skills required. - Strong organizational and time management skills. - Strong character, credibility, ethics, and integrity. - Strong knowledge of clinical care processes and documentation. - Ability to manage large project assignments. - Ability to investigate, analyze, and resolve issues - Ability to interact and garner trust with various levels of staff in the organization by providing practical, sound, accurate, and timely support. - Ability to review and interpret clinical data to determine whether the services are supported by the documentation. - Ability to work independently in a role that requires flexibility in an environment that is deadline-driven with minimal direction from leadership. - The ability to research applicable CMS regulations, MGB charging policies, and payer medical and reimbursement policies - Experience with computer software programs such as Microsoft Office Suite (PPT, Word, Excel, etc.) and Epic. Additional Job Details (if applicable) • M-F 8:00 AM -4:30 PM Eastern Business hours required for remote role • Quiet, secure, stable, compliant work station required Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $62,400.00 - $90,750.40/Annual Grade 6 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. 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