Medical Auditor Resume Sample
Jacynthe Torphy
34667 Rodolfo Plaza,
New York,
NY
+1 (555) 139 4577
Work Experience
Medical Device Lead Auditor
04/2017
-
PRESENT
Phoenix, AZ
- In-services staff members on new & existing policies & procedures. Each auditor is assigned to an Operations team in which the Auditor prepares weekly reviews of the quality. When trends or patterns are identified, the Auditor attends the Daily Dialogue for assigned team & reviews the errors as well as the best practice w/ the Examiners
- Works on problems of moderate scope where analysis of situations or data requires a review of variety of factors. During the audit process the Auditor performs analysis on each claim to determine the root cause of the identified error
- Een boeiende en uitdagende functie in een internationale groep
- Continuously performs audits on medical management functions such as case management, disease management and utilization management for clinical and non-clinical positions to ensure operational quality expectations and regulatory standards are met
- Utilize knowledge of data analysis tools and technology to identify and validate risks
- Documents audits and provides detailed results and feedback to leadership for individual and team results
- Conducts initial evaluation of error origin and seeks trends in data to determine operational efficiencies and recommend process improvements
- Participates in the review, development and implementation of divisional audit tools
Medical Auditor
04/2010
-
11/2016
Dallas, TX
- Effectively responds to and resolves disputes of audit findings working with various levels of leadership
- Drives to and delivers high quality solutions with aggressive timeframes and high level stakeholder satisfaction
- Develops presentations highlighting findings, analysis, recommendations and action plans
- Performs other accountabilities as assigned
- Determines whether services ordered by physicians and rendered to patients are accurately billed and supported by documentation in the clinical record
- Maintains current knowledge of Charge Master system, clinical charging, related systems for the production of a bill and documentation policies and processes
- Gathers data for interpretation and identifies unfavorable trends
CQS Medical Auditor, Group Benefits
03/2003
-
01/2010
Los Angeles, CA
- Facilitates recommendations to improve procedures, strengthen controls, enhance revenue, and improve cash flow
- Reports activity and summary results monthly, quarterly, and annually to Director of Compliance
- Review and understand the client’s Summary Plan Descriptions and Administrative Services Agreement
- Participate in team meetings, conference calls, WebEx’s, etc remotely / locally with administrators and audit team as necessary
- Adherence to The Hartford’s core values
- Develop and maintain the audit process and tools related to: authorizations, appeals, quality events, and case management in CCMS; interrater reliability related to InterQual; and data entry into the credentialing subsystem
- Review work done by various departments within the Service Center, including Claims, Network Operations and Network Development
Education
University of Central Florida
1998 - 2003
Bachelor's Degree in Related Field
Professional Skills
- Effective organizational and prioritization skills with multi-tasking ability
- Strong verbal and written (English language) communication skills
- Strong organizational skills and flexibility to work additional hours as necessary to meet deadlines
- Professional demeanor with strong written communication skills
- Relevant Work Experience: 1 year experience in a healthcare setting required
- Proficient PC navigation and application skills
- Training/experience in quality tools (Kaizen, lean manufacturing, etc.)
How to write Medical Auditor Resume
Medical Auditor role is responsible for training, analysis, manufacturing, mainframe, finance, database, auditing, security, reporting, design.
To write great resume for medical auditor job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Medical Auditor Resume
The section contact information is important in your medical auditor resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Medical Auditor Resume
The section work experience is an essential part of your medical auditor resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous medical auditor responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular medical auditor position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Medical Auditor resume experience can include:
- Knowledge of ICD-10, CPT, and MS-DRG/APC classifications and reimbursement methodologies. 4. Strong problem solving and analytical skills
- Experience researching and interpreting regulations
- Demonstrates initiative in problem solving strategies and recommends corrective action for deficiencies
- Demonstrates the highest level of confidentiality and conducts self according to AHIMA Code of Ethics
- Experience
- Knowledge of HMO, PPO, Medicare and Medicaid plans, as well as experience with Medicare Part D
Education on a Medical Auditor Resume
Make sure to make education a priority on your medical auditor resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your medical auditor experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Medical Auditor Resume
When listing skills on your medical auditor resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical medical auditor skills:
- Strong technical/analytical and problem solving skills
- Florida RN with 3 years recent clinical experience or LPN with 3 years auditing experience
- Maintain thorough and complete knowledge of assigned functional processes to effectively evaluate accuracy levels
- Working experience in a wide range of medical devices, including electromedical devices
- Experience working in a Healthcare setting, physician practice, or hospital
- Solid understanding of the functional activities associated with Credentialing, Provider Relations, Provider Data, Network Development and Claims
List of Typical Experience For a Medical Auditor Resume
1
Experience For Medical Claims Auditor Resume
- Notification to Compliance Manager two weeks prior to audit deadline as to status of audit
- Assist Compliance Training Manager or conduct compliance training sessions for UPP
- Maintains a working knowledge of coding guidelines, regulations, and insurance requirements
- Researches coding and billing questions upon request from a department or practice
- Uses clinical and coding knowledge in performing regular chart audits for compliance, accuracy, completeness, and charge capture
2
Experience For CQS Medical Auditor, Group Benefits Resume
- Consults with managers and staff regarding identification of billing and reimbursement issues
- Attend all Compliance Department staff meetings and any other pertinent Compliance Department meeting
- Close communication with the Billing Department is essential
- Uses clinical knowledge of primary care and specialty procedures to assign the most appropriate coding
- Attend any pertinent department meetings
- Consult with physicians and physician staff, as needed, on documentation issues, requirements for supervision of resident services and other regulatory issues as they arise
3
Experience For Medical Management Auditor Resume
- Develop and manage relationships with colleagues in a professional, independent manner to create and environment that affects necessary change to systems effecting the documentation, billing or coding services
- Established a working knowledge of all departments assigned to the Auditor
- Directs Audit Analyst as required or as requested Compliance Manager or Compliance Officer
- It is also the auditor's responsibility to note areas of determined lost revenue
- Perform internal concurrent or prospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record and that all coding/documentation combinations are compliant with Federal and State regulations
4
Experience For Medical Device Lead Auditor Resume
- Perform internal retrospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record, and that all coding/documentation combinations are compliant with Federal and State regulations
- Report on a weekly basis, status of all assignments, pertinent information obtained during report week, and provide projections for upcoming week to Compliance Manager
- Requests for extension of deadline limited to extenuating circumstances
- Responsible for conducting audit related meetings with Department staff and faculty
- Responsible for evaluating system and/or operational issues throughout UPP
- Reviews work produced by Audit Analyst in detail and provides feedback to Compliance Manager
- Prepares reports and action plans as needed
- Performs audits of patient bills against the medical record, determining accuracy, making changes as necessary and providing corrective intervention to reduce further occurrences
5
Experience For Medical Auditor, Compliance Resume
- Files appeals as needed
- Performs insurance defense and concurrent audits by reviewing the patient medical record and the itemized statement, analyzing discrepancies to ensure charges reflect adherence to physician orders, hospital policy, and accuracy of items and services received
- Provides support as requested to Billing, Admissions, Customer Service and Ancillary departments, by researching and reviewing third-party payor problems and issues for clarification and equitable resolution of charges and services rendered
- Assist departments in creating, testing, and implementing new or updated computer applications within CCHS
- Identifies and tracks departmental trends as determined by third-party audits
- Establishes and maintains communication and rapport with individuals responsible for patient care, i.e. physicians, nursing, pharmacy, lab, radiology, and PT/OT
- Performs special projects and participates in meetings related to cost containment and reimbursement issues
6
Experience For Medical Claim Auditor Resume
- Promotes safe work habits, rules and practices among staff
- Registered RN licensed to practice in the State of Delaware required
- Medical Auditor compares/analyzes clinical documentation or medical records to the patient’s service financial charges/billing information for accuracy on Concurrent, Defense and EDI/Patient Account reviews and enters the data as per procedure
- Understanding of ICD, CPT, HCPCS, APC, DRG, Revenue Codes, NCDs and federal and state guidelines (including CMS NCCI)
- Working knowledge of FDA QSR
7
Experience For Medical Documentation Auditor Resume
- Applies knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities
- Sound understanding or medical terminology and anatomy
- Normalization of large data sets into an existing data warehouse
- Respond to changing requirements, as well as technical issues
- Responsible for evaluating process and/or operational issues throughout UPMC Hillman Cancer Center
- Advanced ICD-10 and CPT coding, anatomy and medical terminology knowledge required
- Coordinates defense audits with external Insurance company representatives
8
Experience For Charge Auditor / Borgess Medical Center Resume
- Works to help streamline charging systems/processes by identifying ongoing charging issues and forwarding the information to the appropriate department(s)/team member(s) for correction and verifies charges for services provided are appropriately posted to patient accounts
- Works cohesively with the audit team
- Analyze and manipulate data within the data warehouse based on predefined guidelines
- Identify trends in large datasets
- Read and interpret complex contract terms into specific test and create custom code to preform those tests
- Generate standard system report
9
Experience For QMS Auditor, Medical Devices Resume
- Create custom ad-hoc reports based on internal and external requests
- Customize system features and functions to meet specific client requirements
- Follow all corporate policies related to data protection and HIPAA
- Works with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client
- Conducts audit of medical records and healthcare claims assessing the accuracy of medical coding and determining compliance with appropriate policies, procedures and regulations
- Prepares and submits detailed reports on audit findings making recommendations to correct deficiencies and/or practice or process improvements
- Maintains current knowledge federal, state and individual payer policy and coding guidelines
10
Experience For Hedis Medical Auditor Resume
- Conducts medical policy and other relevant research in support of review findings
- Uses knowledge of healthcare coding conventions, areas of vulnerability, reimbursement methodologies, and the ability to identify suspicious patterns in medical record documentation
- Conduct research in support of medical review determinations
- Uses clinical and coding knowledge in performing regular chart audits for compliance, accuracy, completeness, and charge capture. Prepares reports and action plans as needed
- Licenses: Certification in auditing, or certification/licensure related to the functional areas being audited would be beneficial
- Review work done by various departments, including Claims, Network Operations and Network Development
- Work proactively with the Manger/Director of Claims Quality Control to ensure quality recommendations are made and implemented
List of Typical Skills For a Medical Auditor Resume
1
Skills For Medical Claims Auditor Resume
- Experience can be in a physician’s office, hospital or insurance office setting
- Or Microsoft SQL Server 2005/2008 experience including stored procedures, views, SQL jobs and database design
- Excellent working knowledge of ISO 13485, MDD 93/42/EEC
- Good manufacturing and technical knowledge of electro-medical devices (active devices); and their relevant harmonized standards
- Experience of conducting MDSAP audits or standalone Technical file reviewer would also be advantageous
- Health related auditing experience
2
Skills For CQS Medical Auditor, Group Benefits Resume
- Registered Nurse or other Healthcare professional (with a Bachelors) and 3 years of health related experience
- Demonstrated track record of achievement with ability to identify and deliver customer expectations
- Demonstrated ability to work independently and make decisions as needed
- Demonstrated ability to evaluate and interpret data
- Knowledge of HMO, PPO, Medicare and Medicaid plans -- including Medicare Advantage plans -- as well as experience with Medicare Part D
- Microsoft SQL Server Reporting Services, Crystal Reports, or like reporting platform
- Responsible for auditing CMS & or Commercial Insurance billing for diagnosis data collected from physician and hospital medical
3
Skills For Medical Management Auditor Resume
- Familiarity with CMS pricing and knowledge of manual pricing requirements especially in relation to multiple procedures
- Fully qualified Medical Device Lead Auditor working for a notified body, or as a Technical File reviewer or as a mixture of both
- Well developed understanding of medical/behavioral health terminology and health management process and procedures
- Position requires 30 to 50% travel throughout the United States
- Position requires frequent travel throughout the United States
- Proficient in the use of Microsoft Office Software (Word, Excel, InfoPath, Visio)
- In-depth knowledge of ICD-10, CPT, HCPCS, revenue codes and medical terminology
- Able to motivate and lead others in a ‘project team’ environment (Desirable)
4
Skills For Medical Device Lead Auditor Resume
- Broad knowledge of care management and regulatory and accreditation standards
- Travel to onsite location – most often at large carrier or third-party administrator
- Conduct audits (either desk-based or on client’s sites) in accordance with established procedures, maintaining a high standard of service delivery that ensures effective customer relationships
- Handle a high volume of telephonic interaction with provider offices
- Follow up on requested medical records with providers
- Thoughtful and methodical search in order to locate specific claim information
- At all times, adopt a safe behaviour by exercising due regard for the health and safety of yourself, colleagues and clients, in line with the Company’s policies and procedures
- Conduct Technical File reviews specific for products being authorized
5
Skills For Medical Auditor, Compliance Resume
- Complete specific projects in relation to medical device procedures, processes, systems and documentation as requested by the Medical Devices Operations Manager
- If required, undertake reviews of packs and make certification decisions within target timescales and in line with SGS policies and accreditation/approval requirements
- Project manage auditing teams, as appropriate, to maximise efficiencies, enhance client satisfaction and ensure compliance with standards
- If required, provide technical support and staff training to all parts of the business in UK and overseas to enhance the service capability of the business
- Knowledge of medical terminology and familiarity with CPT, HCPCS, ICD-9, ICD-10 coding
6
Skills For Medical Claim Auditor Resume
- Two to five (2-5) years of health care audit, data-driven analytics, and/or financial reporting experience preferably within a claims payer and/or benefits consulting environment providing analysis of claims data, contracts, financial arrangements, and claims administration effectiveness
- Experience implementing/auditing to ISO 9001, ISO 14971, JPAL, CMDR and MDD
- Specific experience/training on processes used in the manufacturing of medical devices (ex. sterilization)
- Experience with codes related to medical and dental claims (i.e., ICD, CPT, CDT, HCPCS, Revenue codes, etc.) and identification of coding inconsistencies
- Experience handling multiple projects and assignments in a fast-paced, deadline-driven environment
- Transfer knowledge skill sets to written proposals, reports, and other client communications
- Attention to details; takes initiative to focus on quality (accuracy is critical in calculating and reporting audit results)
- Monitor pending legislation and regulations affecting our services
- Act as primary contact for initiating and coordinating compliance projects, as needed
7
Skills For Medical Documentation Auditor Resume
- Knowledge of claims processing operational and adjudication procedures
- Proficiency with technology (i.e., Access, Excel, Word, PowerPoint) and claims processing systems
- CPMA (Medical Auditing Certification) from accredited source (e.g. American Health Information Management Association, American
- Consistent and methodical review according to established guidelines
- Clearly state what is identified as a deficiency or error in work being reviewed
- Familiarity with fraud detection measures and controls
8
Skills For Charge Auditor / Borgess Medical Center Resume
- Completion of the certification program within 2 years of hire is required
- Knowledge of one or more of the following claims payment systems: IKA, AMISYS, AMISYS Advance Release 4 or 6, NASCO, Facets (latest version), E-Z Cap, Rims, Ocare, Xcelys, NextGen, QNXT, ITS, WGS, Call Care Browser, GBAS, Genelco, HEALTHsuite and Diamond
- Experience with chart review
- Working knowledge of MDD 93/42/EEC
- Detail-oriented with ability to work independently
- Healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required
9
Skills For QMS Auditor, Medical Devices Resume
- Related 3rd party auditing industry management systems experience
- Meet all deadlines (weekly/monthly/quarterly) for review of work
- Work proactively with the Manger of Quality Control to ensure quality recommendations are made and implemented
- Ensure timely and accurate quality data is reported
- Research and assist to define regulatory or accreditation requirements as needed
10
Skills For Hedis Medical Auditor Resume
- Ensure compliance with contract provisions with various agencies and applicable State and Federal laws
- Support Compliance Manager as compliance resource for day–to-day processes
- Support department with regulatory filings as needed
- Analyze and determine the best course of action for each inquiry/problem
- Develop and update plan policies and procedures to ensure compliance with federal and state requirements
- Conduct periodic assessments and audits to ensure compliance with contractual and regulatory requirements and timeliness of submission, as needed
- Oversee the day-to-day health plan policies and procedures to ensure federal and state regulatory compliance, as needed
- All findings are the result of a thorough and complete review of all available documentation and is the responsibility of the auditor to determine if all existing documentation has been reviewed
- Healthcare claims experience helpful
List of Typical Responsibilities For a Medical Auditor Resume
1
Responsibilities For Medical Claims Auditor Resume
- CMDCAS auditor certification
- ETL Development (SSIS)
- This responsibility includes a thorough knowledge of departmental chart and documentation flow, prior to the performance of a medical audit, to assure that documentation review encompasses all available records, as well as working closely with the Department Administrator, Department Chair, Practice Director to provide open communication lines during audit and educational processes
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