The EIO Medical Documentation Auditor ensures accurate & complete documentation through compliance & encounter audits & clinician feedback. Provides documentation feedback to clinicians from E&M, CPT & ICD9 audits conducted by EIO auditors using all state/federal & 3rd party payor regulatory standards for both inpatient & outpatient groups.
Essential Functions:
Using Kaiser Permanente auditing tools, conduct concurrent & retrospective audits of documentation supporting E/M, CPT & ICD9 codes assigned by clinical staff.
Researches correct coding practices in relationship to applicable rules, regulations & coding conventions for billing to determine compliance w/ Federal, State & Kaiser Permanente regulations.
Using independent judgment & sensitivity, reviews w/ individual physicians their audit findings, making suggestions for documentation improvements.
Provides feedback to clinicians based on Federal & State government billing & coding guidelines.
Plans, schedules & performs comprehensive chart audits to identify operational & regulatory issues related to coding, documentation, & compliance requirements & ensure complete & accurate data capture in compliance w/ Federal & State requirements.
Works w/ Medical Center auditing teams to ensure compliance w/ Federal, State & Kaiser Permanente requirements.
Designs & implements methodologies to ensure accurate & complete E&M, CPT & ICD9 coding audits.
Provides technical expertise to Regional & local leadership to identify & resolve coding & chart documentation problems impacting the accuracy & consistency of coded data.
Works w/ local Trainers to address operational processes that hinder encounter data capture.
Reads & interprets medical data written by providers.
Enters audit results into regional audit tools to support quality assurance process, regional analysis & regional training activities.
Reviews analytical data & audit findings to identify coding trends & other risk areas. Recommends appropriate actions.
Conducts quality assurance reviews.
Collaborates in the development & execution of local audit & training plans.
Partners w/ the EIO Managers to identify audit trends & risk areas based on audit findings & data analysis.
Assists in developing & implementing policies & procedures / Compliance Audit Standards to ensure compliance w/ Federal, State & other regulatory requirements.
Travel throughout the Northern California region based on operational needs may be required.
In addition to the standard auditor accountabilities, the EIO Auditor is also responsible for conducting Claims & Referral audits.
Responsible for independently implementing the end to end audit process for claims & referrals following established objectives w/ expected completion & accuracy goals.
Partners w/ Provider Contracting to assess status of claims based on whether associated vendor is a contracted or non-contracted partner. Negotiation approach will need to be tailored to the type of vendor.
Manage vendor relationship to get access to documentation which requires client management skills & travel to offsite locations.
Develops a strategy to get access to pertinent medical record information & all supporting documents that need to be audited.
Conducts audit independently on-site per audit objectives & guidelines.
Secondary Functions:
Proficiency in Excel and Access (Candidate will utilize these software tools to perform in-depth analytical review of codes and provide outcomes in clear concise manner)
Qualifications
Basic Qualifications:
Three (3) or more years CPT, ICD9 & E&M Coding experience.
Experience using PC applications such as MS Word, Excel, Access & PowerPoint.
Demonstrated experience conducting Medical Record audits & ability to interpret & apply Federal & State regulations, coding & billing requirements.
Experience using Epic electronic health record systems preferred.
Experience using Web based applications preferred.
Medical center operations or clinical experience preferred.
Bachelor's degree in business administration, health care, public health, finance, business medical records technology or equivalent experience.
Certification in one (1) of the following: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H).
Proficient in the use of CPT, ICD9 & HCPCS coding principles.
Comprehensive knowledge of medical diagnostic & procedural terminology is required.
Demonstrated ability to constructively & sensitively provide feedback to providers & medical center leadership regarding federal & state coding, medical documentation & compliance guidelines, audit results & risk areas.
Ability to work w/ & maintain confidentiality of physician, patient, patient account & personnel data.
Knowledge of outpatient coding practices at both the clinical & inpatient settings.
Required knowledge of compliance & regulatory requirements including outpatient CMS regulations.
