Coding Audit Specialist, Health Plan

40000 Sanford Health Plan; Wisconsin; Hybrid; USD 30,000 - 48,000; Full time

Job summary

Sanford Health is seeking a Coding Audit Specialist to ensure accurate risk adjustment coding across Medicare Advantage, ACA/Exchange and BadgerCare Plus populations. You will audit medical records, apply CPT/ICD-10 guidelines, and present concise audit outcomes to leadership.

Ideal candidates have CPC certification within a year, 3 years in health insurance or auditing, and strong knowledge of CMS guidelines, documentation standards, and data analysis.

Qualifications

• High school diploma or equivalent; knowledge of anatomy/physiology and medical terminology.
• 3 years of experience in health insurance, compliance, quality assurance, or auditing.
• Certified Professional Coder (CPC) certification within one year of hire.

Responsibilities

• Audit medical records to ensure correct codes for Medicare Advantage, ACA/Exchange, and BadgerCare Plus.
• Develop and monitor risk adjustment auditing program with leadership.
• Review provider documentation and verify code assignment to ensure documentation supports reported codes.

Skills

Medical coding knowledge

CMS guidelines knowledge

Documentation review

Analytical skills

Education

Associate Degree in coding/health-related field

Certified Professional Coder (CPC) certification

Tools

Microsoft 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

Department Details 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].

The Sanford organization owns and manages multiple distinct brands, including Sanford Health, Marshfield Clinic, and Good Samaritan, as well as Lewis Drug, Sanford Health Equip, Solutions by Sanford, Great Shots, and Blue Rock Bar & Grill.

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.

Headquartered in Sioux Falls, South Dakota, the organization has 53,000 employees and serves over 2 million patients and nearly 425,000 health plan members across the upper Midwest including South Dakota, North Dakota, Minnesota, Wyoming, Iowa, Wisconsin and the Upper Peninsula of Michigan.

The integrated nonprofit health system includes a network of 56 hospitals, 288 clinic locations, 147 senior care communities, 4,000 physicians and advanced practice providers and nearly 1,500 active clinical trials and studies.

The organization’s transformational virtual care initiative brings patients closer to care with access to 78 specialties.

Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

Good Samaritan, one of the nation’s largest nonprofit providers of senior care and services, is committed to transforming the aging experience through innovation, compassion and personalized care.

As part of Sanford Health, an integrated nonprofit health system headquartered in Sioux Falls, South Dakota, Good Samaritan serves 10,000 seniors and offers access to a full continuum of care, including 94 rehabilitation and skilled nursing centers, 56 assisted living and memory care facilities, 44 independent living locations and 37 home health and hospice agencies.

The senior care provider delivers services across the upper Midwest, with 70% of residents living in rural communities.

Learn more about Good Samaritan’s mission and commitment to delivering high quality senior care in rural America at good-sam.com.