Integrated Revenue Integrity
Revenue Integrity Auditor
Integrated Revenue Integrity, Oklahoma City, Oklahoma, United States
Managing Principal at Integrated Revenue Integrity
Working under the direction of an IRI Principal, the Consultant will perform outpatient hospital coding, billing, and reimbursement audits and related revenue cycle initiatives. This role supports clients by ensuring accurate coding, compliant billing, and appropriate reimbursement for outpatient services, with a focus on regulatory compliance, revenue optimization, and industry best practices. The Consultant must demonstrate strong analytical skills, attention to detail, and a thorough understanding of outpatient hospital reimbursement methodologies.
Responsibilities
Outpatient Coding Audits: Review outpatient medical records and claims to validate accurate code assignments in accordance with ICD‑10‑CM, CPT, HCPCS, modifiers, and applicable outpatient billing rules.
Billing and Reimbursement Review: Evaluate outpatient hospital claims for compliance with CMS and payer‑specific billing and reimbursement requirements, including APC methodology and OPPS guidelines.
Revenue Integrity Audits: Assess charge capture processes to ensure services are appropriately documented, coded, and billed, identifying revenue leakage and compliance risks.
Denial Analysis and Resolution: Analyze outpatient claim denials, identify root causes, and recommend corrective actions to reduce future denials and improve reimbursement outcomes.
Documentation Review and Education: Identify documentation gaps impacting coding and billing accuracy and provide feedback and education to support documentation improvement.
CDM Review Support: Review outpatient charge builds and CDM components to validate code assignments, revenue codes, and modifiers.
Regulatory Monitoring: Stay current with outpatient regulatory, coding, and reimbursement changes and apply updates to audit findings and client guidance.
Client Support: Respond to client inquiries related to outpatient coding, billing, reimbursement, compliance, and audit findings.
Professional Development: Maintain required certifications and ongoing education through webinars, seminars, and other training opportunities.
Competencies
Demonstrates critical thinking, sound judgment, and the ability to work independently in a remote consulting environment.
Strong organizational and time management skills with the ability to manage multiple projects and meet deadlines.
Maintains high standards of accuracy, professionalism, and integrity in audit work and client interactions.
Excellent verbal and written communication skills, with the ability to clearly present findings and recommendations to clients and leadership.
Strong attention to detail with the ability to identify trends, risks, and improvement opportunities.
Minimum Qualifications and Education Requirements
Minimum of 5 years of experience in hospital outpatient coding, billing, reimbursement, auditing, or revenue cycle operations.
At least 3 years of hands‑on outpatient coding and/or auditing experience.
Strong knowledge of outpatient hospital billing guidelines, including CPT/HCPCS coding, modifiers, revenue codes, NCCI edits, and OPPS/APC reimbursement.
Experience working with hospital EHR and billing systems (e.g., Epic, Cerner, Meditech, CPSI).
Working knowledge of payer policies, medical necessity requirements, and claim billing processes.
Solid understanding of healthcare regulatory requirements, including CMS regulations, HIPAA, Stark Law, and Anti‑Kickback Statute.
Proficiency with Microsoft Office applications, including Word, Excel, and PowerPoint.
Preferred Skills
Bachelor’s degree in Health Information Management, Healthcare Administration, Business, Finance, or a related field.
7–10 years of progressive experience in hospital outpatient revenue cycle or auditing roles.
Prior consulting experience or experience as a Revenue Integrity Analyst or Auditor.
Advanced analytical skills with the ability to interpret complex outpatient billing and reimbursement data.
Experience providing education, audit summaries, and actionable recommendations to clinical and revenue cycle stakeholders.
Boston, MA $72,500.00 — $105,000.00 1 month ago
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Responsibilities
Outpatient Coding Audits: Review outpatient medical records and claims to validate accurate code assignments in accordance with ICD‑10‑CM, CPT, HCPCS, modifiers, and applicable outpatient billing rules.
Billing and Reimbursement Review: Evaluate outpatient hospital claims for compliance with CMS and payer‑specific billing and reimbursement requirements, including APC methodology and OPPS guidelines.
Revenue Integrity Audits: Assess charge capture processes to ensure services are appropriately documented, coded, and billed, identifying revenue leakage and compliance risks.
Denial Analysis and Resolution: Analyze outpatient claim denials, identify root causes, and recommend corrective actions to reduce future denials and improve reimbursement outcomes.
Documentation Review and Education: Identify documentation gaps impacting coding and billing accuracy and provide feedback and education to support documentation improvement.
CDM Review Support: Review outpatient charge builds and CDM components to validate code assignments, revenue codes, and modifiers.
Regulatory Monitoring: Stay current with outpatient regulatory, coding, and reimbursement changes and apply updates to audit findings and client guidance.
Client Support: Respond to client inquiries related to outpatient coding, billing, reimbursement, compliance, and audit findings.
Professional Development: Maintain required certifications and ongoing education through webinars, seminars, and other training opportunities.
Competencies
Demonstrates critical thinking, sound judgment, and the ability to work independently in a remote consulting environment.
Strong organizational and time management skills with the ability to manage multiple projects and meet deadlines.
Maintains high standards of accuracy, professionalism, and integrity in audit work and client interactions.
Excellent verbal and written communication skills, with the ability to clearly present findings and recommendations to clients and leadership.
Strong attention to detail with the ability to identify trends, risks, and improvement opportunities.
Minimum Qualifications and Education Requirements
Minimum of 5 years of experience in hospital outpatient coding, billing, reimbursement, auditing, or revenue cycle operations.
At least 3 years of hands‑on outpatient coding and/or auditing experience.
Strong knowledge of outpatient hospital billing guidelines, including CPT/HCPCS coding, modifiers, revenue codes, NCCI edits, and OPPS/APC reimbursement.
Experience working with hospital EHR and billing systems (e.g., Epic, Cerner, Meditech, CPSI).
Working knowledge of payer policies, medical necessity requirements, and claim billing processes.
Solid understanding of healthcare regulatory requirements, including CMS regulations, HIPAA, Stark Law, and Anti‑Kickback Statute.
Proficiency with Microsoft Office applications, including Word, Excel, and PowerPoint.
Preferred Skills
Bachelor’s degree in Health Information Management, Healthcare Administration, Business, Finance, or a related field.
7–10 years of progressive experience in hospital outpatient revenue cycle or auditing roles.
Prior consulting experience or experience as a Revenue Integrity Analyst or Auditor.
Advanced analytical skills with the ability to interpret complex outpatient billing and reimbursement data.
Experience providing education, audit summaries, and actionable recommendations to clinical and revenue cycle stakeholders.
Boston, MA $72,500.00 — $105,000.00 1 month ago
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