Coding Auditor Educator

Highmark Health; Pennsylvania; Hybrid; USD 39,000 - 61,000; Full time

Job summary

Highmark Health is seeking a Coding Auditor to perform internal, concurrent, prospective and retrospective coding audits. You will review medical records to ensure data quality and accuracy of coding, billing and documentation for DRGs, APCs, CPTs and HCPCS Level II codes, and ICD diagnoses and procedures.

You will develop training programs, provide guidance, and collaborate with management and external consultants to improve documentation and reimbursement compliance in line with HIPAA and

Qualifications

• Auditing experience in medical coding and documentation is required.
• Strong knowledge of ICD-CM/ICD-PCS, CPT/HCPCS, and DRG/APC structures.
• Certification from AAPC or AHIMA is required; RHIT/CCS preferred.
• At least 5 years of hospital or physician coding/auditing experience; teaching experience is a plus.

Responsibilities

• Plans and conducts audits of documentation, coding and billing at AHN entities.
• Develops and delivers training materials to address deficiencies per regulatory requirements.
• Provides written audit guidance and participates in external audit findings reviews.
• Communicates results to management and affected areas; supports education programs.
• Ensures compliance with coding guidelines and regulatory requirements; mentors staff.

Skills

Auditing experience

Medical coding knowledge

Analytical skills

Communication skills

Education

AAPC or AHIMA certification

RHIT/CCS credentials preferred

5 years hospital/physician coding/auditing

Tools

Encoder software

Grouper

Abstracting software

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, grouper, abstracting and other related software.
• Strong analytical and communication skills
• Preferred Associate's Degree
• 3 years with claims processing and data management
• Past auditing and strong education/training background in coding and reimbursement

Disclaimer:

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement:

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range

Minimum: $28.19

Maximum: $44.13

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.