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Job Details

Healthcare Validation Auditor

Requisition #: 294185
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Non-Clinical Professional
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Dec. 1, 2020

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.

Position Summary

The Healthcare Validation Auditor is responsible for validating the payment integrity audit findings associated with the algorithms developed both internally and externally. The Auditor will analyze, review, and audit claims interpreting the Health Plans fee schedules, claims edits, provider agreements, and claims processing rules to identify and confirm overpayments produced by Payment Integrity (PI).

The Auditor is primarily responsible for auditing overpayments that span across Fee Reimbursement, Payment Policy, Benefit Configuration, COB, or Medical Policy. The Auditor will research and stay abreast of all coding guidelines and industry-standard rules.

Task requirements for position

  • Review the focused claims audits delivered through the payment integrity workflow to identify exceptions to established claims adjudication requirements for post-payment activities
  • Audits include but are not limited to retroactively terminated members, multiple reductions procedures, duplicated claims, NCCI, MUEs, Anesthesia, and focused audit types
  • Research member activity to identify Coordination of Benefits, Third Party Liability, Subrogation as identified through member admissions, authorization process and external vendor activities
  • Auditing claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements
  • Ability to research CMS, Industry Standard (other commercial plans) and Health Plan reimbursement practices, policies, and methods of claims payments
  • Apply knowledge of provider billing and patient accounting practices to reveal overpayment recovery opportunities.
  • Load inpatient and outpatient terms to contractual or workflow software
  • Respond professionally and accurately to all departmental inquiries within the required timelines
  • Contribute new ideas for improving existing audit processes and audit queries
  • Work cohesively with the audit team and the client

Requirements:

  1. Education:

BA/BS preferred not required

B. Knowledge:

Provider billing and patient accounting practices
All healthcare standard billing codes (CPT4, ICD-9, HCPCS, and Revenue Codes) preferred

C. Skills:

Independent thinker, able to focus with minimal distraction and keen attention to detail
Effective verbal and written communication skills
Organizational skills; ability to multitask, set priorities, and meet deadlines

D. Required Licensure, Certification, Etc.:

Not applicable

E. Work Experience:

7 plus years of healthcare provider reimbursement experience specific to managed care claims processing or auditing
3 plus years of experience with claims processing with FACETS, QNXT, MS-400 or HealthSuite

F. Machines, Tools, Equipment:

Auditor will utilize general office and communication equipment including an assigned computer, electronic mail, telephone systems, fax machine, etc. Microsoft Office Products: Word, Excel, PowerPoint, Access, routine Office Equipment: PC, telephone, fax, etc.

Dimensions:

A. Budget Responsibility:

Effectively uses resources within his or her control.

B. Authority/Decision Making Level:

Works independently with limited supervision.

C. Supervisory Responsibility:

No direct supervisory responsibility. The Auditor will provide guidance and support to leadership and staff.

Problem Solving:

Ability to creatively solve problems, deal with ambiguity

Information Management:

Manages department information. Must understand and agree to maintain the confidential nature of information obtained in the course of work including medical, billing and compliance data as well as HIPAA related data.

Working Conditions:

Works in a normal office environment where there are no physical discomforts due to dust, dirt, noise and the like.

Work requires considerable attention to detail (approximately 60% of time) which may produce a high level of mental and/or visual fatigue.

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.

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