Clinical Auditor

Position Description

The individual in this position reviews eligibility and service documentation related to private insurance, ADM, TANF, CFBHN, and Medicaid. Provides technical assistance and expertise as needed to assure compliance with all private insurance, ADM, TANF, CFBHN, FIS, and Medicaid policies/procedures including determination of benefits, pre-certification, concurrent reviews, quality reviews, submission of claims, and collection of unpaid claims. This person works closely with individuals who directly complete service data and financial data entry into the Electronic Health Record System.

Position Expectation

In keeping with the mission and core values of Tri-County Human Services, all persons served, stakeholders, and fellow employees will be treated with dignity, respect, and shown sensitivity to their cultural diversity.

Primary Duties and Responsibilities

1. Reviews randomly selected files reviewing same files for purpose of determining effective utilization and quality management of services provided.
2. Works with those who directly input documentation to coordinate billing for CFBHN, TANF, FIS, Medicaid and private insurance to assure compliance with agency policy. Verifies person served eligibility and verifies billing eligibility. Maintains statistical database for Medicaid, TANF, FIS/MSS and other insurance eligibility.
3. Reviews clinical records for eligibility to determine proper insurance reimbursement, identifies billable services that do not meet insurance documentation requirements. Advises Program Supervisors (or designee) of billing opportunities and missed opportunities and provides consultation to unit staff/supervisor regarding documentation necessary to bill said services.
4. Reviews billing for those services eligible for reimbursement and reviews payment vouchers for accuracy upon receipt of it.
5. Advises unit staff when fee adjustments are necessary due to documentation inadequacy.
6. Maintains an up-to-date knowledge base regarding Medicaid, TANF, FIS/MSS, and CFBHN/private insurance documentation and billing requirements through attendance at seminars and workshops.
7. Provides on-going education to staff regarding insurance standards in order to assure that staff is able to comply with said standards.
8. Assists in the development of agency policies and procedures regarding determination of benefits, pre-certification, concurrent reviews, quality reviews, submission of claims, follow-up on un-paid claims, and appeals procedures. Acts as a resource for the agency staff regarding these issues.
9. Trains and instructs assigned support staff at outlying facilities on the proper billing and audit procedures to assure compliance at the facilities with internal and external requirements.
10. Recommends needed action including disciplinary action to staff/supervisor with consult of Chief Executive Officer and/or Compliance Director.
11. Required to meet and maintain TCHS Approved Driver Qualifications per policy number 100.007.52.
12. Provides other duties as assigned.

Minimum Training and Experience

• Bachelor's Degree in social work, mental health or another related field.
• Preference of a Master's Degree and a LCSW, or LMHC license or equivalent.
• Computer skills
• Knowledge of Medicaid/private insurance documentation and billing procedures
• Knowledge of coordination of benefits and billing procedures for said benefits
• Strong organizational skills
• At least two (2) years full-time experience in a setting where the aforementioned knowledge and skills were utilized.
• Displays capability to monitor the quality documentation and service utilization trends.

Tri-County Human Services, Inc. is an equal opportunity employer. M/F