Coding Auditor Educator

highmarkhealth; Pennsylvania; Hybrid; USD 70,000 - 100,000; Full time

Job summary

Allegheny Health Network is seeking a seasoned Coding Auditor to perform audits of medical records for coding accuracy and documentation quality. You will train staff, review DRG/APC structures, and ensure adherence to ICD-CM/ICD-PCS and CPT/HCPCS guidelines to support compliant coding.

Responsibilities include developing audit reports, presenting findings, and coordinating with external auditors and management to drive process improvements and education efforts across AHN facilities.

Qualifications

• High school diploma or GED is required.
• AAPC or AHIMA credentials (RHIT/CCS) for inpatient or outpatient.
• AAPC outpatient credentials (CPC/COC/CPMA) are required.
• 5 years hospital or physician coding/auditing experience; includes education techniques and methods.
• Deep knowledge of ICD-CM/ICD-PCS, CPT/HCPCS; DRG/APC structure and guidelines.

Responsibilities

• Plans, conducts audits and reports on coding, documentation and billing.
• Develops training materials and educates staff to address deficiencies identified in audits.
• Validates coding systems and ensures compliance with DRG/APC structure and regulatory requirements.
• Interacts with external auditors and management to improve documentation and processes.

Education

High school diploma or GED

AAPC/AHIMA credentials (RHIT/CCS, CPC/COC/CPMA)

Job description

Company : Allegheny Health Network Job Description :

GENERAL OVERVIEW:

Performs all related internal, concurrent, prospective and retrospective coding audit activities. Reviews medical records to determine data quality and accuracy of coding, billing and documentation related to DRGs, APCs, CPTs and HCPCS Level II code and modifier assignments, ICD diagnosis and procedure coding, DRG/APC structure according to regulatory requirements. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, training, process changes, risk reduction, optimization of reimbursement with new and current coders in accordance with coding principles and guidelines. Promotes cooperation with CDMP and compliance programs to improve documentation which supports compliant coding. Interacts with external consultants regarding billing, coding and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines

ESSENTIAL RESPONSIBILITIES:

• Plans and \conducts audits and reports on the documentation, coding and billing performed at AHN entities. Reviews, develops and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements. Provides written audit guidance. Participates with management in the assessment of external audit findings and responds as needed. Attends meetings and interacts with management to resolve issues and provide advice on new programs. Provides guidance to system entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Determine appeal action, prepare appeal letter follow up and identify education issues. (20%)
• Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact and profitability. Conducts education/training or works with external resources to present final audit findings to department staff, physicians and appropriate individuals. (20%)
• Validates the ICD-CM, ICD-PCS, CPT and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements. Performs periodic claim form reviews to check code transfer accuracy from the abstracting system and the chargemaster. (10%)
• Is responsible for or works with external resources to create and monitor inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends and variations in the facilities frequently assigned DRG/APC groups. Once identified, evaluate the cases of the change or problems and takes appropriate steps to effect resolution. (10%)
• Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD-CM ICD-PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC. (10%)
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines. Assures compliance with the coding guidelines and regulatory requirements. (10%)
• Performs other duties as assigned or required including training/mentoring of new staff, performing audits and research related to special projects and providing coverage for coding manager(s). (10%)
• Depending on location provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology and disease processes as it relates to the DRG/APC and other clinical data quality management factors. With technical direction and assistance from management, designs and implements coder education program, continuing education programs and Medical Staff education programs. Establishes and monitors performance and maintains appropriate documentation thereof. (10%)
• Other duties as assigned.

QUALIFICATIONS:

• Minimum
• High school diploma / GED
• Certification from American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) AHIMA Credentials (Inpatient or Outpatient): Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS)
• AAPC Credentials (Outpatient): Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA)
• 5 years with hospital or physician coding and/or auditing, as well as, education techniques and methods. (Internal transfer and promotion candidates may have a minimum of 3 years experience)
• In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems. Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective payment system and Coding Clinic references. Current working knowledge of encoder, gr