Responsibilities

Under the general direction of the Manager of Health Information Management, the Audit and Appeals Coordinator coordinates recovery audit contracting activities to ensure that deadlines are adhered to. The Audit and Appeal Coordinator is responsible for hospital compliance with all federal, state and regulatory agencies to manage payer audits and appeals. Assumes the role of system administrator for the Audit and Appeals software product.

These duties will require the understanding of many complex and varying guidelines, systems, regulations and tools. The Audit and Appeals Coordinator will use critical thinking skills to manage an ever-evolving process that includes financial, clinical and legal components. The Audit and Appeals Coordinator will proactively work with GVH staff and physicians to put processes in place and to correct identified deficiencies that are impacted by retrospective denials.

Essential Functions:

• Acts as central contact for sending and receiving correspondence related to Recovery Audit Contractor (RAC), and other payer post discharge denials.
• Coordinates deadlines with hospital staffing including, but not limited to, Health Information Management, Case Management and other hospital departments and outside vendors.
• Assumes responsibility for meeting audit and appeals deadlines for the health system.
• Assumes responsibility as system administrator of the denials tracking tool, including database tables to support the RAC and other post-discharge denials programs.
• Responsible for ensuring required data is entered into denials tracking tool to produce accurate metrics.
• Provides HIM leadership with metrics and reports from the Audit and Appeals software system to track appeals activity.
• Performs scheduled reconciliations of the tracking tool to ensure no requests are in jeopardy of not meeting a deadline.
• Notifies HIM Director when changes or problems to the process are identified.
• Maintains a fast-paced process of requests and acknowledgements for data and correspondence.
• Coordinates with management to identify and correct weaknesses with billing and financial reimbursement.
• Maintains current third-party appeal information in the database in order to provide accurate reporting at various hospital committees. Provides updates until closed or overturned.
• Maintains all correspondences and receipt acknowledgements in the file to ensure receipt by payers.
• Continues to educate oneself and impacted hospital areas and staff on audit and appeal industry and program regulations. Stays current on trends related to medical necessity, DRG and automated denials by the RAC and other payers.
• Executes The Joint Commission audits as requested by management.
• Performs core measure abstraction monthly or as deemed necessary for the organization.
• Manages PHC4 data delivery and review to meet regulatory deadlines.