Coding Auditor Senior

Highmark Health; Pennsylvania; Hybrid; USD 47,000 - 75,000; Full time

Job summary

Highmark Health is seeking a senior coding auditor to evaluate medical records for accuracy of DRG, OPPS and outpatient billing. You will generate findings, train staff, and guide improvements across system entities.

You will interact with external auditors and consultants, ensuring compliance with HIPAA and CMS guidelines. The role requires deep knowledge of DRGs, CPT and ICD coding, plus strong analytical and communication skills.

Qualifications

• Bachelor’s Degree and RHIA certification or 10+ years in medical records.
• AHIMA or AAPC credentials listed for inpatient/outpatient.
• 7+ years hospital coding and auditing experience.
• Proficient with DRGs, ICD-10, and CMS coding guidelines.
• Strong written and verbal communication; ability to train staff.

Responsibilities

• Audit documentation, coding and billing across system entities.
• Develop and deliver training materials addressing audit deficiencies.
• Consult with management; provide written guidance on external audit findings.
• Attend meetings to advise on new programs and resolve issues.
• Maintain knowledge of DRGs, CPT, ICD coding and CMS changes.
• Mentor staff and act as subject matter expert.

Skills

Documentation and reporting

Communication

Microsoft Word

Excel

PowerPoint

Education

Bachelor’s Degree

RHIA/ RHIT / CCS / CPC-H / CPC / COC / CPMA

Tools

CMS guidelines

DRGs

ICD coding

Job description

Company

Allegheny Health Network

Job Description

GENERAL OVERVIEW: Senior most coding auditor who evaluates medical records to determine the accuracy of coding, billing and documentation related to DRG, OPPS and outpatient claims. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, process changes and risk reduction. Provides guidance to System entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. 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

• Audits and reports on the documentation, coding and billing performed at System entities.
• (25%) Reviews, develops and delivers training programs and educational materials which address deficiencies identified in the audits.
• (25%) Consults with management. Provides written 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.
• (20%) Maintains coding knowledge and billing regulations associated with DRGs, CPT coding, ICD diagnosis and procedures coding and changes in CMS regulations.
• (20%) Acts as mentor and subject matter expert for staff.
• Performs other duties as assigned or required. (5%)

QUALIFICATIONS

• Minimum Bachelor’s Degree and Registered Health Information Administrator (RHIA) certification or ten (10) years’ experience in a medical record setting and one (1) of the following certifications from a certifying body must apply: 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 Hospital Outpatient (CPC-H), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA)
• Minimum of 7 years’ experience in hospital coding and auditing as well as experience in educational techniques and methods
• Must be proficient in Diagnosis Related Groups (DRGs), National Correct Coding Initiatives, ICD 10 Official Guidelines, Outpatient Prospective Payment System and Coding Clinic references
• Strong analytical and communication skills are required
• Knowledge of reimbursement systems and regulations pertaining to health information (HIPAA, CMS, etc.)
• Proficient writing skills, preparation of reports and training materials and presentation of clear and concise information (oral and written) are also required
• Ability to effectively communicate findings to staff as well as senior management and external regulatory agents
• Proficient in use of Microsoft Word, Excel and PowerPoint
• Preferred Master’s Degree.

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

Pay Range Minimum: $34.29 Pay Range Maximum: $54.25

Minimum: $34.29

Maximum: $54.25

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.

About Highmark Health

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. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at [e-mail] 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.