Coding Audit Specialist, Health Plan

sanford; United States; On-site; USD 45,000 - 72,000; Full time

Job summary

Sanford Health is seeking a Coding Audit Specialist to perform quality assurance on CMS and DHS risk adjustment data. You will audit medical records, ensure accurate diagnostic coding, and develop monitoring programs for Medicare Advantage, ACA/Exchange, and BadgerCare Plus populations.

The role requires knowledge of CPT, ICD-9/10, HCC coding and strong documentation review skills; certification within one year is expected.

Qualifications

• High school diploma or equivalent required; proficiency in anatomy/physiology and medical terminology.
• Associate degree in coding or health-related field preferred.
• Three years in health insurance, compliance, quality assurance or auditing; ICD-9/10, CPT, HCC coding knowledge.
• Familiarity with CMS guidelines affecting Medicare Advantage, HHS-ACA and DHS/BadgerCare Plus.
• Certified Professional Coder and/or Certified Risk Adjustment Coder within one year of hire.

Responsibilities

• Audit medical record documentation to ensure correct codes are used.
• Develop and monitor risk adjustment score auditing programs for Medicare Advantage, ACA/Exchange and BadgerCare Plus.
• Identify un-coded or mis-coded diagnoses; provide outcomes and tools for accuracy improvements.
• Ensure documentation supports reported codes per CPT, ICD-9/10 guidelines and CMS policy.
• Present audit findings in a concise, logical summary.

Skills

Anatomy/physiology knowledge

Medical terminology

Auditing

Documentation accuracy

Education

High school diploma or equivalent

Associate degree in coding or health-related field

Tools

Word

Excel

Access

Job description

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.

Work Shift

Day (United States of America)

Scheduled Weekly Hours

40

Compensation

Salary Range: $21.50 - $34.50

Union Position

No

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.

Job Description

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.
• 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 1-877-949-5678 or send an email to [e-mail].