Code and Documentation Compliance Specialist-CFHP

University Health System- San Antonio; San Antonio (TX); On-site; USD 30,000 - 52,000; Full time

Job summary

Community First Health Plans is seeking a Code and Documentation Compliance Specialist-CFHP to join the SIU team. The role focuses on advanced coding audits, data collection, and generating statistical reports to support compliance with federal and state regulations.

The candidate will conduct investigations related to fraud and abuse, review eligibility, claims, and provider contracts, and help educate staff and physicians based on findings from audits.

Qualifications

• Five years of experience with ICD-10-CM/DRG assignment, chart auditing, and CPT4 coding.
• Knowledge of ICD-10 and Microsoft Office products.
• Must have completed a Certified Coding Program or Health Information Management Program to qualify for reduced experience.

Responsibilities

• Audit coding and documentation to ensure compliance with federal and state laws.
• Research eligibility, claims payments, benefits, prior authorization/referrals, and contracts.
• Identify overpayments to providers and assist with anti-fraud initiatives.
• Conduct investigations related to fraud and abuse under SIU supervision.

Skills

ICD-10-CM/DRG assignment

Chart auditing

CPT4 coding

Data reporting

Microsoft Office

Education

High school diploma or equivalent

Certified Coding Program or Health Information Management Program

Tools

Microsoft Office

Job description

Code and Documentation Compliance Specialist-CFHP

Community First Health Plans

TPA DCHP COMPLIANCE AND RISK MANAGE

Full Time

Day Shift

Salary Range: $22.10 - $38.25

POSITION SUMMARY/RESPONSIBILITIES

Functions under the direct supervision of the Special Investigations Unit (SIU) Manager. Performs at the advanced skill level of a Coding Specialist. Is adept at data collection and statistical report generation. Demonstrates individual judgement, initiates work improvement methods. Will conduct administrative investigations related to fraud and abuse. Will conduct research related to eligibility, claims payment, benefits, prior authorization/referrals and contract review. Responsible for conducting and reviewing audits to assess the quality of coding and documentation to ensure compliance with federal and state laws and regulations. Responsible for researching and compiling documentation that may be reported to external regulatory and law enforcement agencies. Research and audit for accurate provider and facility payments. Identifies overpayments to provider. Assists provider, employee and contractors with the Community First Health Plan's anti-fraud program. Conducts routine education programs for staff and physicians to communicate findings from investigations, coding and documentation audits.

EDUCATION AND EXPERIENCE

High school diploma or its equivalent is required. Five years of experience with ICD-10-CM/DRG assignment, chart auditing, and CPT4 code assignment is required or only two years of experience if candidate has successfully completed a Certified Coding Program or Health Information Management Program. Must be knowledgeable of ICD-10. Must be knowledgeable of Microsoft Office products.