Under the direction of the Supervisor of Medical Audit, the Clinical Audit Coordinator I, assures the appropriate payment of claims through the identification and retrospective audit of claims and medical records. Depending on the number of records to be reviewed, the position will require either an in-house audit or an onsite review at the provider's place of business. Determines whether the medical record documentation supports the coding billed and claims paid correctly using various coding and reimbursement guidelines. Notifies the provider of audit findings giving them the opportunity to appeal within a designated time frame. Submits adjustments to the appropriate department to accurately reflect the services rendered and/or reimbursement. Identifies and reports to management, suspected fraudulent billing practices and providers in need of education. May work on special projects as assigned, in addition to daily work responsibilities. Qualifications: RN with current NYS license, preferred or other allied health professional with current NYS license required. Knowledge of Federal and State regulations and accreditation standards. Knowledge of provider reimbursement and all...

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