The Compliance Medical Auditor performs audits and monitoring of clinical documentation analyzing medical records assessing the accuracy of ICD-10-CM/PCS, CPT or HCPCS codes; determining compliance with appropriate policies, procedures, and regulations. Identifies and recommends strategies for process improvement. Prepares written reports on findings. Maintains an up-to-date working knowledge on regulatory requirements associated with outpatient and procedure area coding and billing and claims processing. The incumbent will participate in all aspects of the organization’s Compliance Program.
Essential Duties and Responsibilities:
- Conduct medical record documentation and coding/billing audits, assessing the accuracy of ICD-10-CM/PCS, CPT, HCPCS codes, modifier assignments, etc.; determining compliance with appropriate policies, procedures, and Federal and state regulations. Identify procedural and system weaknesses and offer guidance to Management for process improvements.
- Conduct audits according to the Compliance work plan and as requested. Plan and organize work assignments to complete projects in an efficient manner. Produce high-quality work that is competently and efficiently performed in accordance with department standards. Prepare comprehensive reports, making recommendations to correct deficiencies and practice or process improvements.
- Monitor to identify patterns, trends and variances related to auditing and monitoring projects.
- Conduct follow-up audits if indicated to appraise the adequacy of corrective actions and determine whether deficiencies are corrected; prepare the appropriate reports for management.
- Provide coding and documentation guidance to medical and coding staff and management as needed.
- Participate in the design and implementation of a risk based annual compliance audit work plan incorporating governmental and other agency regulations, internal Compliance Program requirements, and operational policies and procedures. Prepare and present quarterly reports of incumbent’s projects to the Compliance Leadership.
- Keep abreast of related coding guidelines and reporting requirements. Maintain professional skills and knowledge through attendance at relevant conferences, seminars and other educational programs; participate in professional organizations; and review current literature.
- Adheres to the Organizational policies and procedures
- Maintains strict confidentiality of client, company and personnel information
- Demonstrates a strong commitment to the mission and values of the organization
- Adheres to company attendance standards
- Performs other duties as assigned
Supervisory Responsibilities: None
- Knowledge of billing rules and regulations.
- Strong organizational and interpersonal skills
- Excellent written and verbal communication skills
- Detail oriented
- Ability to multi-task and work independently
- Knowledge of medical and dental coding systems
- Knowledge of medical terminology
Education and/or Experience:
Bachelor’s degree required.
- 1-3 years of experience performing coding for outpatient or procedure area preferred.
- Experience conducting coding, documentation and billing/claims audits required.
Certificates, Licenses, Registrations:
Certification in Health Care Compliance or Graduate Certificate in Health Care Compliance preferred as well as one of the following coding certifications through American Health Information Management Association or the American Academy Professional Coders: Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P), Certified Professional Medical Coder (CPC), or Professional Medical Coder Outpatient Hospital (COC).
Proficiency using a Windows computer platform
Experience with electronic medical record and billing platforms
Ability to learn new systems quickly
Environmental Factors/Physical Demands:
Work is performed in an office environment with some travel required in this position. While performing the duties of this job, the employee is regularly required to drive. Must have the ability to maintain active customer communication; access, input and retrieve information for the computer system, enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to sitting for long periods of time, bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.