Revenue Cycle Lead Auditor

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A Brief Overview
The Revenue Cycle Lead Auditor performs audits of higher risk and complex revenue cycle related activity, from patient registration to final payment, and serves as the departmental technical knowledge expert on revenue cycle processes. This position involves conducting thorough audits to verify adherence to revenue cycle policies, payer requirements, and regulatory standards. The Lead Auditor will analyze revenue cycle data to identify discrepancies, trends, and areas for improvement, ensuring compliance with healthcare regulations such as HIPAA and CMS guidelines. Staying updated on changes in these regulations is essential to effectively scope revenue cycle audits and make recommendations to mitigate risks associated with non-compliance. Upholding the organization's values and maintaining patient confidentiality are paramount in this role, as is the commitment to continuous quality improvement and compliance with all regulatory requirements.

The Lead Auditor conducts or supervises the work of other staff in testing and reviewing controls within their assigned revenue cycle related sub-processes. The Lead Auditor determines the audit project scope and test plan to ensure that audit objectives are achieved as outlined in the Internal Audit Plan approved by the Audit, Compliance and Risk Committee of the Boards of Trustees and in accordance with professional standards and budgeted time resources. The position ensures that audit projects have value-added results that enhance controls and/or identify opportunities to improve financial and/or operational performance. The Lead Auditor is responsible for preparing detailed audit reports that include findings, recommendations, and corrective action plans. These reports must be communicated to relevant stakeholders, including department heads and senior management, to facilitate informed decision-making. Collaboration with various departments which perform key revenue cycle functions is crucial to identify and make recommendations for process improvements that mitigate gaps in controls, optimize revenue capture, and minimize revenue leakage. The Lead Auditor provides coaching and/or training to less experienced auditors and reviews their work product.

The Lead Auditor maintains and updates the revenue cycle audit universe, co-leads the associated risk assessments, and provides audit project recommendations for inclusion in the annual Internal Audit Plan. The Lead Auditor also works with management to follow-up on the implementation status of corrective actions related to previously reported audit observations. It is expected that the Lead Auditor will be viewed by operating management as a key resource for which they can seek guidance on revenue cycle risk and control issues.

What you will do

• Conducts and/or leads complex revenue cycle audit engagements, including special projects in accordance with department and professional standards. For each audit project, performs planning activities including establishing audit objectives and scope based on a risk assessment.
• Develops the testing strategy and related audit programs.
• Conducts or supervises the testing performed, as well as the development of recommendations to improve internal controls for risks identified.
• Conducts entrance and exit conferences.
• Drafts audit reports and presents results to management.
• Maintains the revenue cycle audit universe, co-leads the associated annual risk assessment, and recommends audits for inclusion in the Internal Audit Plan.
• Works with management to follow-up and determine the implementation status of previously reported audit findings for their respective sub-processes to assess resolution and corrective action taken by management.
• Provides coaching and mentoring to less experienced staff. Provides oversight and serves as a technical expert resource on the assigned entity sub-process.
• Compliance Reviews: Ensure compliance with applicable healthcare regulations, including Medicare and Medicaid billing rules, coding standards, and payer contracts.
• Denial Management: Analyze denied claims, identify root causes of denials, and make recommendations for the appeal and resolution of outstanding issues with payers.
• Data Analysis: Analyze billing trends, identify patterns of errors, and generate reports to highlight areas for improvement within the revenue cycle.
• Contract Interpretation: Understand payer contracts and identify potential reimbursement issues and opportunities based on contract language.
• Collaboration: Work with revenue cycle, financial clearance and other departments to address identified issues.

Education Qualifications

• Bachelor's Degree Healthcare Administration, Health Information Management, Accounting, Business, or a related field Required
• Master's Degree Preferred

Experience Qualifications

• At least five (5) years of experience in healthcare revenue cycle management, including experience with claims auditing, denial management and clinical documentation integrity, or similar role in academic medical center Required
• Experience in Internal Audit, public accounting or a related financial/operational position Preferred
• Project Management experience Preferred

Skills and Abilities

• Excellent interpersonal skills to deal with all levels of management (Required proficiency)
• Demonstrated ability to work independently (Required proficiency)
• Demonstrates thoroughness, creativity, foresight, and use of sound business judgment in the application of accounting principles, corporate policies, and business practices (Required proficiency)
• Must have self-motivation, initiative, and broad thinking coupled with a sense of urgency (Required proficiency)
• Must have initiative and ability to handle multiple projects simultaneously (Required proficiency)
• Clinical Knowledge: Basic understanding of medical terminology and clinical practices to interpret patient records (Required proficiency)
• Software Proficiency: Expertise in electronic health records (EHR) systems and billing software (Required proficiency)
• Third Party Payer Practices: Knowledge of third-party payer practices including precertification, filing deadlines, claims processing, coverage issues and referral requirements (Required proficiency)
• Analytical Skills: Strong analytical abilities to identify patterns, trends, and potential areas of revenue leakage (Required proficiency)
• Attention to Detail: High level of accuracy and meticulous attention to detail when reviewing medical records and billing data. (Required proficiency)

Licenses and Certifications

• Certified Revenue Cycle Representative (CRCR) - Healthcare Financial Management Association - - Preferred or
• Certified Internal Auditor (CIA) - Institute of Internal Auditors - - Preferred or
• Certified Public Accountant (CPA) - Pennsylvania State Licensing Board - - Preferred

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must be fully vaccinated against COVID-19 and receive an annual influenza vaccine. Learn more.

Employees may request exemptions for valid religious and medical reasons. Start dates may be delayed until candidates are immunized or exemption requests are reviewed.

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