Stanford Health Care is a division of Stanford Medicine—a segment of Stanford University. As an employer, Stanford Health Care has offered job opportunities t
Government Audit & Appeals Specialist I
Location
United States
Posted
20 days ago
Salary
$46 - $60 / hour
Seniority
Mid Level
Job Description
Government Audit & Appeals Specialist I
Stanford Medicine
Role Description The Government Audit Analyst and Appeal Specialist play a critical role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position requires a strong understanding and application of clinical documentation, coding, and regulatory requirements, as well as excellent analytical and communication skills. The Government Audit Analyst and Appeal Specialist will collaborate with clinical staff, coding professionals, and external stakeholders to ensure timely and accurate resolution of appeals, ultimately contributing to the financial health of the organization. There are three (3) career banded levels within the Revenue Cycle specifically within the Denials Management Team. Positions are flexibly staffed at any of the three levels and progression from one level to the next higher level depends on: - The need for a position at the higher level - The nature, scope and complexity of the duties assigned - An employee's demonstrated and applied knowledge, skills and abilities and professional behaviors Government Audit Analyst and Appeal Specialist I is the entry, developmental and first working level of the Government Audit Analyst and Appeal Job Family. Work is limited to less complex audits and appeals work. Non-routine problems/issues are referred to a higher level. Completed assignments are reviewed for conformance with standards, policies, and procedures. What you will do - Adhere to Stanford Health Care’s organization competencies and Code of Conduct. - Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures. - Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments. - Identify instances of overpayments and underpayments. - Compose professional and comprehensive appeal letters to payors after a detailed review of medical records. - Ensure compliance with Medicare, Medicaid, third-party guidelines, Local Coverage Determinations (LCD), National Coverage Determinations (NCD), clinical documentation, coding guidelines, and payor policies. - Create comprehensive appeal strategies based on relevant guidelines and documentation. - Draft and submit detailed appeal letters along with supporting documentation. - Provide a thoughtful appealability score for each denial under review. - Review and edit appeals for clarity and accuracy prior to submission. - Ensure medical record documentation supports medical necessity and all services billed. - Work closely with clinical teams, coding specialists, physicians and other departments. - Identify and escalate denial patterns to the Manager of Government Audits and Appeals. - Complete all assigned tasks by established deadlines. - Stay updated on changes in healthcare regulations, payor policies, and industry best practices. - Actively participate in developing appeal templates, audit tools, goals, policies, and procedures for the Denials Management Department. Qualifications - Associate’s degree in a work-related discipline/field from an accredited college or university (or equivalent combination of education/experience) - Required - Bachelor’s degree in a work-related discipline/field from an accredited college or university - Preferred Requirements - Minimum three (3) years of progressively responsible, related work experience in healthcare revenue cycle management, with at least two (2) of those years being in a role which included claim-related appeal writing - Required - Minimum two (2) years’ experience in medical coding - Required - EPIC EHR and 3M Encoder experience - Required Required Knowledge, Skills and Abilities - Ability to manage, organize, prioritize, multi-task, and adapt to changing priorities while meeting deadlines. - Ability to communicate effectively in written and verbal formats. - Extensive writing capabilities and efficiencies. - Ability to influence outcomes through convincing arguments supported by data. - Ability to apply critical thinking skills to identify patterns and trends. - Ability to mediate and solve complex work problems and issues. - Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500). - Experience with coding, clinical validation, and medical necessity for inpatient stays. - Knowledge of third-party payor rules and regulations. - Knowledge of local, state, and federal healthcare regulations. - Knowledge of detailed healthcare corporate compliance functions and audits. - Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust. - Ability to maintain confidentiality of sensitive information. - Proficiency in computer systems, specifically EPIC and 3M. - Proficiency in computer software, including Microsoft Word, Excel, and Power Point. Licenses and Certifications - CCS - Certified Coding Specialist required Upon Hire - Certified Professional Medical Auditor (AAPC-CPMA) required Upon Hire - COC - Certified Outpatient Coder required Upon Hire Benefits - Base Pay Scale: Generally starting at $45.94 - $59.73 per hour - The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training.
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Specialist in Psychiatry and Psychotherapy
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