Coding Audit Specialist, Health Plan

Good Samaritan Society; South Dakota; Hybrid; USD 30,000 - 48,000; Full time

Job summary

Sanford Health, the largest rural health system in the United States, seeks a Coding Audit Specialist to ensure the accuracy of CMS/DHS risk adjustment data. You will audit medical records for correct coding (CPT, ICD-9/10, HCPCS) and develop monitoring programs across Medicare Advantage, ACA/Exchange, and BadgerCare Plus.

Requirements include a high school diploma, 3 years in health insurance or auditing, and CPC/CRCoder within one year.

Qualifications

• High school diploma or equivalent required with knowledge of anatomy/physiology.
• Coursework in CPT, ICD-9 and ICD-10 coding required.
• Three years of experience in health insurance, compliance, QA, or auditing.
• Certified Professional Coder and/or Certified Risk Adjustment Coder within 1 year of hire.
• Proficiency with Word, Excel, and Access.

Responsibilities

• Audit and ensure accuracy of CMS and DHS risk adjustment data.
• Audit medical records to determine correct diagnostic coding per CPT/ICD guidelines.
• Develop and monitor a continuous monitoring program for Medicare Advantage and ACA/BadgerCare.
• Prepare concise audit summaries presenting findings clearly.
• Maintain knowledge of CPT, ICD-9/10, HCPCS, and CMS guidelines.

Skills

Anatomy/physiology

Medical terminology

Word

Excel

Access

Education

High school diploma or equivalent

Associate degree in coding/health field

Tools

CPT coding

HCPCS coding

ICD-9/ICD-10 coding

Job description

Careers With Purpose

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world‑class health care in America’s heartland.

• Facility: Remote SD (Central Time)
• Location: Remote, SD
• Address:
• Shift: Day
• Job Schedule: Full time
• Weekly Hours: 40.00
• Salary Range: $21.50 - $34.50

Job Summary

The Coding Audit Specialist position conducts quality assurance activities to ensure the accuracy and integrity of risk adjustment data submitted to the Centers for Medicare & Medicaid Services (CMS) and Department of Health Services (DHS); identifies deficiencies and provides management with an analysis of outcomes and tools for improving accuracy in coding. Responsible for auditing medical record documentation to determine appropriate diagnostic coding for services provided, taking into account the AMA CPT coding guidelines, ICD‑9 & ICD‑10 Coding Guidelines, CMS Medicare, HHS, and DHS BadgerCare Plus risk adjustment policy and Hierarchical Condition Category Coding. Develops, implements and monitors, along with risk adjustment leadership, to provide a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange and Medicaid/BadgerCare Plus member diagnosis documentation. Audits medical record documentation to ensure correct codes have been selected and to detect un‑coded or miscoded diagnoses for the Medicare Advantage, ACA/Exchange and BadgerCare Plus member populations. Develops and maintains the skills necessary to accurately audit the coding for visits (evaluation and management) and procedures documented by physicians, hospitals and other providers in the various specialties and subspecialties as it relates to HCC coding. Maintains knowledge of CPT coding rules, ICD‑9 and ICD‑10 codes, HCPCS codes, HCC coding, use of modifiers, documentation guidelines, CMS Policy requirements, and other reimbursement guidelines to ensure accurate documentation review and diagnosis code assignment. Reviews components of the provider's documentation and compares the documentation with the requirements of the code(s) reported to verify that documentation supports the code(s) reported. Formulates an outcome for each audit, identify correct or incorrect coding to ensure audit findings are presented in a logical, concise summary.

Qualifications

High school diploma or equivalent required. Demonstrated knowledge of anatomy/physiology and medical terminology. Completion of courses in Current Procedural Terminology and , ICD‑9 and ICD‑10 coding required.

Associate Degree in coding and/or health‑related field preferred.

Three years of experience required in a health insurance, compliance, quality assurance, or auditing related position. Experience with ICD‑9, ICD‑10, CPT, HCC and HCPCS coding. Knowledge of the different CMS guidelines that affect Medicare Advantage, HHS‑ACA and DHS/BadgerCare Plus members as related to revenue management.

Demonstrated knowledge of Word, Excel, and Access.

Certified Professional Coder and/or Certified Risk Adjustment Coder certification awarded by American Academy of Professional Coders required within one year of hire.

Benefits

Sanford offers an attractive benefits package for qualifying full‑time and part‑time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home‑work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits .

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to [e-mail] .

Sanford has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre‑employment background screening as a condition of employment.

• Req Number: R-0273982
• Job Function: Health Plan
• Featured: No