Internal Coding Auditor
Full TimeJob Description: Internal Coding Auditor
GENERAL OVERVIEW:
Plans and conducts institutional medical record, billing, research, and non-coding compliance audits for documentation, billing, and compliance with state and federal requirements (audits may include: outpatient clinics, outpatient procedures, ancillary services, activities in accordance with Stark requirements, physician professional fees or post-acute care services including homecare, outpatient hospice, infusion, and durable medical equipment). Presents audit findings to hospital/physician leadership, creates appropriate audit spreadsheets, provides educational presentations to hospital departments/physicians/ practice staff as applicable to correct audit concerns. Completes special coding billing and documentation audits.
ESSENTIAL RESPONSIBILITIES:
- Performs internal concurrent, prospective, and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding, billing, and documentation is compliant with appropriate guidelines and federal and state regulations. Develops audit detail summary spreadsheets and reports to address any coding, documentation, or financial discrepancies.
- Conducts presentations of final audit findings to department staff, physicians, and appropriate individuals. Works with auditees on corrective action plans and educates management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, and coding requirements.
- Responsible for defending payor claims denials for medical necessity, coding, billing, and documentation through coordination of and participation (when appropriate) in the appeal process – RACs, ZPICs, MICs and OIG audits and other payors as assigned.
- Performs internal concurrent, prospective, and retrospective audits to assure that research services and bills are supported by documentation in the medical record, that research activities coincide with study protocol approved by the IRB, and that all documentation is compliant with federal and state regulations.
- May provide guidance to hospital entities and performs reviews as needed in response to external medical necessity audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, IRB, etc.
- Post-Acute Care Auditor Only: Supports non-audit related compliance program activities for post-acute care as needed including completion of Medicare 855s and other regulatory or licensure paperwork, and research/interpretation of new/existing regulations.
QUALIFICATIONS:
Minimum
- For facility (Inpatient/ Outpatient) or professional fee auditor: at least/or equivalent to some of the following RHIT, RHIA, GCS, CCS, CCS-P, CPC, CIC, COC.
You will be trained to:
- Gain knowledge and understanding of healthcare billing practices and compliant claims preparation for both governmental and commercial payers.
- Achieve coding certification: Global Coding Specialist – GCS
Continuing Education: Certified Clinical Coders will be provided with education opportunities to fulfill the required continuing education hours to maintain current and proper national/International certification (GCS) requirements for this position. - Possess a working knowledge of Medicare and Local Medical Review Policy Guidelines.
- Ability to function independently and as a team player in a fast-paced environment required.
- Knowledge of computing/coding observation hours.
- Knowledge of coding infusions and injections.
- Knowledge of surgical/Outpatient coding.
- Knowledge of inpatient coding.
- Knowledge of Evaluation and Management coding.
- Maintain the company accuracy rating of 98%.
- Meet set weekly quota for productivity. This is a production coding environment and can be fast paced.
- Knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).
- Knowledge of reimbursement systems, including Prospective Payment System (PPS); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS).
- Practical knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.
- Practical knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology).
- Make well-informed, effective, and timely decisions, even when data are limited, or solutions produce unpleasant consequences; perceives the impact and implications of decisions.
- Utilize medical computer software programs to abstract, analyze, and/or evaluate clinical documentation and enter/edit diagnosis, procedure codes and modifiers.
- Clearly express information (for example, ideas or facts) to individuals or groups effectively, considering the audience and nature of the information. Speaking and writing (specifically email) in an organized manner.
- Display courtesy, empathy, and tact, developing and maintaining effective relationships with others; effectively work with individuals who are difficult, hostile, or distressed to resolve differences; and be able to relate well to people from varied backgrounds and in different situations.
- Work with internal and external customers to assess their needs, provide information or assistance, resolve their problems, or satisfy their expectations.
- Contribute to maintaining the integrity of the organization; display high standards of ethical conduct and understand the impact of violating these standards on an organization, self, and others.
- Be open to and embrace change and new information; adapt behavior or work methods in response to new information, changing conditions, or unexpected obstacles; effectively deals with uncertainty.
- Cooperate by willingly accepting new assignments and forming relationships with customers/co-workers/supervisors.
- A high level of effort and commitment towards performing the work, using efficient learning techniques to acquire and apply new knowledge and skills; uses training, feedback, or other opportunities for self-learning and development.
- Understand and interpret written material, including technical material, rules, regulations, instructions, reports, charts, graphs, or tables; applies what is learned from written material to specific situations. Working Excel knowledge.
- Attention to detail and completeness with a thorough understanding of government rules and regulations, medical coding and reimbursement guidelines, and potential areas of risk for fraud.
- Work planning is necessary in being able to understand assignments and establish priorities. It is required that each coder be able to look at his/her workload and determine priorities for the day.
- Ability to respond to email or text correspondence in a timely manner
CHIM International and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. CHIM International and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EOE is The Law
Equal Opportunity Employer:
CONTACT:chemminger@chiminterational.com
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