Coding and Compliance Auditor
Analyzes and reviews medical documentation and ensures application of all appropriate procedural codes, diagnosis codes and modifiers to all Professional and Outpatient fee services identified for auditing purposes. Analyzes records for appropriateness of documentation and ensures compliance with all Federal, State and third party payer rules and regulations. Reviews and analyzes Governmental and third party payer requests such as ADR’s, CERT, RAC, pre-payment probes and audits to ensure billed services are in compliance with applicable rules and regulations for each payer. Reviews medical record and prior billing statistics by provider and patient to ensure adherence to Local and National Coverage decisions including billing parameters. Assists manager with all sample reviews on departmental and provider charting, provider and billing staff in-services and training. Provides physician, clinical staff and billing personnel with coding and billing education in conjunction with accurate procedural and diagnostic coding assignment and sequencing. Enters audit findings into Compliance data base to produce required audit attestations and reporting. Ensures audit findings are accurately entered and depicted in applicable billing systems status post review.
1. Manages and adheres to assigned audit schedule as outlined in the Departmental Compliance Workplan and the Professional Practice Billing Compliance Program. Performs all annual prospective compliance audits, re-audits and concurrent reviews as necessary and required. Analyzes and reviews medical documentation and billing data for all pertinent internal and external audits. Acts as liaison between Compliance Department and the Clinical and Administrative staff to ensure audit results are disseminated and understood.
2. Assists in developing and implementing policies and procedures for the department, ensuring that they conform to all Federal, State and local carrier regulations. Keeps abreast of current regulations and all regulatory changes in order to conduct accurate audits and reviews.
3. Conducts random sample reviews and focused audits adheres to guidelines of the Professional Practice Billing Compliance Program. Reviews pertinent medical records to determine all appropriate procedural, diagnostic codes and modifiers are assigned by the Outpatient Clinical areas and/or charging systems in addition to the Faculty Practice physicians and/or groups.
4. Reviews medical records for adherence to all Teaching Physician Guidelines and other applicable Federal, State and third party regulations. Identifies documentation deficiencies for non-compliance in these areas and reports data to Manager.
5. Assists in conducting in-services for providers and billing personnel on documentation requirements, coding assignments and insurance carrier billing requirements. Ensures that documentation, coding and billing requirements are fully understood.
6. Performs data input and analysis; monitors all pre-, post- and third party carrier reviews and provides necessary education and training as needed.
7. Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental, and infection control standards.
OTHER JOB DUTIES
Identifies records needed for special studies (e.g., data collection, government agencies); compiles information and provides to requestor.
Performs other related duties as required.
Bachelor’s degree in a relevant field or equivalent in education and experience required.
Current CCS-P, or CPC certification required
5 years of experience of ICD-9CM and CPT-4 coding (or other applicable successor coding systems) in a multi-specialty physician or Outpatient facility environment required. 2-5 years of third party billing and reimbursement experience.
Strong knowledge of documentation requirements, unbundling edits and physician/outpatient hospital billing requirements including reimbursement methodologies.
Good oral and written communication skills.
Good interpersonal skills.
Speaks, reads and writes English to the extent required by the position; knowledge of a second language preferred.