Job Summary :
The Revenue Integrity Auditor identifies billing and coding discrepancies, potential compliance violations, revenue leakage, overpayments, underpayments, documentation deficiencies, and operational control weaknesses. The role develops audit findings, recommends corrective and preventive actions, monitors remediation efforts, and collaborates with Revenue Cycle, Health Information Management (HIM), Coding, Patient Financial Services, Clinical Documentation Integrity (CDI), Compliance, Privacy, and Information Security teams to promote sustainable compliance and financial integrity.
Job Description
Essential Responsibilities:
Comprehensive Revenue Integrity Auditing: Conduct routine, focused, retrospective, and risk-based audits across the healthcare revenue cycle, including patient registration, eligibility, authorization, charge capture, coding, billing, claims submission, payment posting, and account adjustments.
Perform end-to-end account audits to validate the accuracy and completeness of patient encounters, charges, supporting documentation, claim submission, reimbursement, and financial transactions.
Evaluate compliance with internal policies, standard operating procedures, payer contracts, reimbursement methodologies, and applicable regulatory requirements.
Identify revenue leakage, missed charges, duplicate charges, inappropriate write-offs, unsubstantiated adjustments, billing errors, and reimbursement variances.
Assess the effectiveness of revenue cycle controls and recommend improvements to reduce compliance risk and prevent recurring errors.
Develop and maintain audit plans, sampling methodologies, audit tools, workpapers, and supporting documentation.
Medical Coding, Clinical Documentation, Billing and Claims Compliance: Audit ICD-10-CM/PCS, CPT, HCPCS Level II, and other applicable coding for accuracy, completeness, specificity, and consistency with supporting medical record documentation.
Evaluate appropriate assignment of diagnoses, procedures, modifiers, units of service, place of service, and other claim elements, as applicable.
Review compliance with official coding guidelines, National Correct Coding Initiative (NCCI) edits, medically unlikely edits, and payer-specific billing policies.
Assess medical necessity, documentation sufficiency, and the appropriateness of billed services in accordance with applicable coverage and reimbursement requirements.
Identify potential upcoding, undercoding, unbundling, duplicate billing, unsupported services, and other coding or billing practices that may create compliance exposure.
Collaborate with coding and CDI teams to clarify documentation deficiencies, validate audit findings, and support education and corrective action.
Provide recommendations for coding corrections, claim adjustments, and other appropriate remediation in accordance with organizational policy and applicable law.
Review outpatient, inpatient, and facility claims, as applicable, for accurate charge reporting, coding, billing, and reimbursement.
Validate compliance with Medicare, Medicaid, commercial payer, and other applicable billing requirements.
Evaluate claim edits, denials, rebilling practices, late charges, and adjustments for accuracy and compliance.
Identify patterns involving inappropriate reimbursement, unsupported charges, missed revenue opportunities, and preventable claim denials.
Escalate potential improper payments, suspected fraud, waste, abuse, and significant billing compliance concerns through established reporting channels.
HIPAA Privacy, Regulatory Compliance, Risk Assessment, and Confidentiality Auditing: Assess revenue cycle workflows for compliance with applicable HIPAA Privacy Rule and Security Rule requirements and organizational privacy and security policies.
Evaluate appropriate access to PHI, minimum-necessary practices where applicable, secure handling of medical records, and appropriate use and disclosure of information during billing, coding, auditing, and…