This is a remote position.
Job Summary:
The Medical Documentation Auditor ensures accurate and complete documentation through compliance and encounter audits and clinician feedback. Provides documentation feedback to clinicians from E&M, CPT, and ICD9 audits conducted using all state/federal and third-party payor regulatory standards for outpatient groups.
Essential Responsibilities:
Core Audit Responsibilities:
- Conduct concurrent and retrospective audits of documentation supporting E/M, CPT, and ICD9 codes assigned by clinical staff.
- Research correct coding practices in relation to applicable rules, regulations, and coding conventions for billing to determine compliance with Federal, State, and third-party payor regulations.
- Review audit findings with individual physicians, making suggestions for documentation improvements.
- Provide feedback to clinicians based on Federal and State government billing and coding guidelines.
- Plan, schedule, and perform comprehensive chart audits to identify operational and regulatory issues related to coding, documentation, and compliance requirements.
- Ensure complete and accurate data capture in compliance with Federal and State requirements.
- Design and implement methodologies to ensure accurate and complete E&M, CPT, and ICD9 coding audits.
- Provide technical expertise to leadership to identify and resolve coding and chart documentation problems impacting the accuracy and consistency of coded data.
- Work with Trainers to address operational processes that hinder encounter data capture.
- Enter audit results into audit tools to support quality assurance processes, analysis, and training activities.
- Review analytical data and audit findings to identify coding trends and other risk areas and recommend appropriate actions.
- Conduct quality assurance reviews and collaborate in the development and execution of audit and training plans.
- Assist in developing and implementing policies and procedures to ensure compliance with Federal, State, and other regulatory requirements.
Requirements
Qualifications:
- Minimum three (3) years CPT, ICD9, and E&M Coding experience.
- Bachelor's degree in business administration, health care, public health, finance, business medical records technology, or four (4) years of experience in a related field.
- High School Diploma or General Education Development (GED) required.
- Certification as a Certified Coding Specialist, Certified Professional Coder - Hospital Outpatient, Registered Health Information Administrator, Registered Health Information Technician, or Certified Professional Coder.
- Proficient in the use of PC applications such as MS Word, Excel, Access, and PowerPoint.
- Experience conducting Medical Record audits and interpreting and applying Federal and State regulations, coding, and billing requirements.
- Comprehensive knowledge of medical diagnostic and procedural terminology.
- Ability to provide constructive and sensitive feedback to providers and leadership regarding federal and state coding, medical documentation, and compliance guidelines.
- Ability to work with and maintain confidentiality of physician, patient, patient account, and personnel data.
- Knowledge of outpatient coding practices.
- Strong interpersonal, written, verbal, and presentation skills.
- Ability to work independently with minimal supervision, prioritize workload, and meet deadlines.
- Ability to read and interpret medical data.
- Willingness to be flexible depending upon department and/or physician schedule needs.
- Experience using electronic health record systems and web-based applications preferred.
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