Code and Documentation Compliance Specialist-CFHP

University Health; San Antonio (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

University Health seeks a Coding Specialist within the SIU framework to conduct audits, analyze coding and documentation for compliance, and identify potential provider overpayments. The role involves data collection, report generation, and staff education on investigation findings.

Strong knowledge of ICD-10-CM/DRG assignment and CPT4 coding is required, with five years of related experience or two years with a coding certification program. Proficiency in Microsoft Office is expected.

Qualifications

• Must know ICD-10 and CPT4 coding conventions.
• Experience auditing charts and reviewing eligibility and claims.
• Proficiency with Microsoft Office applications.

Responsibilities

• Conduct audits to assess coding accuracy and documentation quality.
• Identify overpayments and report findings to regulators or payers.
• Educate staff on coding, investigations, and audit results.

Skills

Data collection

Statistical report generation

Auditing

Research

ICD-10-CM/DRG knowledge

CPT4 coding

Microsoft Office

Education

High school diploma

Certified Coding Program or Health Information Management Program

Job description

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.