Coding Auditor

The Coding Auditor demonstrates expertise in coding and billing compliance while performing audits to determine billing integrity of professional and facility/technical fees including detection and correction of documentation, coding and billing errors and/or medical necessity of services billed. Audits consist of evaluation of the adequacy and accuracy of documentation in support of services billed including ICD-10/CPT/HCPCS and other third party payor codes, DRG and EAPG assignments, medical necessity of the services, reimbursement overpayments and underpayments, and compliance with other documentation, coding and billing standards. The Coding Auditor applies standardized audit scoring methodology to consistently evaluate documentation and coding, and standardized audit findings methodology to report audit results. Minimum Education

Associate's Degree Candidates with 3 years of coding experience in lieu of the degree requirement will be considered. .

Minimum Work Experience

2 years as a Certified Coder preferably with experience in pediatric coding and/or experience performing coding audits within an academic medical center (Required)

Required Skills/Knowledge

Interpret and apply documentation and coding rules and regulations along with charge capture and reimbursement methodologies;

Plan, conduct and perform coding audits;

Work cooperatively with Medical Center administrative staff, department staff, and providers;

Manage diverse and conflicting priorities and projects effectively and meet deadlines;

Maintain competence in and up-to-date knowledge of healthcare billing and coding compliance requirements, practices and trends;

Conduct detailed coding audits, reach independent decisions and logical conclusions and prepare report of findings;

Interpret medical records progress notes, hand written and electronic chart entries, provider orders, and other related documentation;

Proficiency in the use of personal computers with Windows operating systems including Microsoft applications such as Word, Excel, Outlook, PowerPoint and Access.

Communicate effectively both verbally and in writing.

Required Licenses and Certifications

CCS, CIC, CPC, CPC- H, or COC. (Required)

CPMA and/or CEMA/C or ability to acquire within 6 months after start date. (Required)

Functional Accountabilities

Performs scheduled and unscheduled independent audits of professional fee documentation, coding and medical necessity related to professional service providers such as physicians and NPPs (Non-Physician Providers) as well as facility/technical fee billing audits (inpatient and outpatient) as assigned.

Conducts specialized and focused audits.

Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation.

Evaluates the appropriateness of ICD-10, HCPCS and CPT codes, APC/EAPG, DRG, and admission assignments, along with modifier usage.

Evaluates accuracy of supply and implant charge capture and coding based on Medical Center policies and related payor requirements.

Makes determinations of overpayments and underpayments and performs other related analysis and evaluations.

Adheres to the defined audit timeline and audit protocol standards.

Assists with development of the audit schedule.

Identifies services to be audited.

Applies consistent and standardized billing audit methodology for sample selection, scoring and benchmarking development and reporting of findings. Reports findings in standardized format by established deadline so findings can be appropriately communicated.

Maintains knowledge of current Medicare, Medicaid and other third party payor billing and documentation requirements.

Meets department expectations about daily productivity targets and deadlines

Creates educational material for clinical and non-clinical staff.

Other duties as assigned

Organizational Accountabilities

Organizational Accountabilities (Staff)

Organizational Commitment/Identification

Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

Demonstrate collaborative and respectful behavior

Partner with all team members to achieve goals

Receptive to others’ ideas and opinions

Performance Improvement/Problem-solving

Contribute to a positive work environment

Demonstrate flexibility and willingness to change

Identify opportunities to improve clinical and administrative processes

Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

Use resources efficiently

Search for less costly ways of doing things

Safety

Speak up when team members appear to exhibit unsafe behavior or performance

Continuously validate and verify information needed for decision making or documentation

Stop in the face of uncertainty and takes time to resolve the situation

Demonstrate accurate, clear and timely verbal and written communication

Actively promote safety for patients, families, visitors and co-workers

Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance