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Healthcare Compliance Specialist
4 weeks ago
We are seeking an experienced Healthcare Compliance Specialist to join our team. As a key member of our Clinical Audits team, you will be responsible for conducting onsite and desktop clinical coding reviews to ensure hospital claiming compliance.
Key Responsibilities- Conduct regular onsite and desktop provider audits, managing end-to-end processes, including follow-up and financial management of incorrect billing.
- Review specific details of hospital claims to advise on incorrect or inappropriate DRG, ICD, or ACHI coding/billing practices.
- Validate provider-initiated DRG review requests based on coding and documentation analysis.
- Provide clinical/coding standards advice on statistical reports produced by Data and Claims Analysts to determine if further investigation and action is warranted.
- Initiate, write, develop, and continually improve relevant data reports to identify areas of actual and potential claims leakage based on Bupa Hospital and Medical contracts.
- Tertiary qualifications in Health Information Management or Clinical Coding.
- Extensive experience gained in healthcare clinical coding auditing, preferably within a hospital or health insurance setting, conducting compliance investigations, hospital, or claims audits (essential).
- Advanced clinical coding experience and a practical understanding of their impacts on Diagnosis Related Groups (essential).
- Familiarity with national, state, and territory coding guidelines in Australia.
- Understanding of private hospital contract management practices and concepts.
- Understanding of Hospital Purchaser Provider Agreement contracts and relationship to claims.
- Proven experience in data report writing and interpretation.
A competitive salary of $120,000 - $150,000 per annum, depending on experience. Additionally, we offer a range of benefits, flexible working arrangements, and opportunities for professional growth and development.
About UsBupa is an international healthcare group committed to helping people live longer, healthier, happier lives. With over 70 years of experience, we operate in Australia, New Zealand, and Hong Kong, supporting millions of customers through various health and care services.
