Coding Compliance Auditor

UTMB Health; Galveston (TX); On-site; USD 65,000 - 95,000; Full time

Job summary

UTMB Health in Galveston, TX seeks an experienced Coding Auditor with CCS credentials to audit professional and hospital billing for accuracy and compliance. The role requires applying CPT/ICD-10-CM/PCS guidelines and participating in education initiatives to address identified issues.

You will collaborate with Compliance and Billing teams to monitor documentation quality and ensure audits reflect regulatory standards. Monday–Friday, on-site at UTMB Health facilities.

Qualifications

• Bachelor's degree or equivalent and at least four years of relevant experience.
• Certified Coding Specialist (CCS) by AHIMA required.
• Strong knowledge of CPT, ICD-10-CM/PCS, DRG and HCPCS coding principles.

Responsibilities

• Audit documentation and coding for professional, hospital/facility inpatient and outpatient billing.
• Select and conduct random or focused audits using auditing software.
• Review documentation to ensure compliance with CMS and MACs rules and third-party guidelines.

Skills

Auditing

Healthcare compliance

CMS regulations knowledge

Education

Bachelor's degree or equivalent

AHIMA CCS certification

Job description

Minimum Qualifications:

Bachelor's degree or equivalent and at least four years of relevant experience. Certified Coding Specialist (CCS) by the American Health Information Management Association (AHIMA) required.

Job Summary:

Utilize advanced skills necessary to audit documentation, coding, and reimbursement of professional, hospital/facility inpatient and outpatient billing. Ensure that documentation is complete and accurately reflects/supports the coded level of service. Audits will determine if the billed services are consistent with medical record documentation and in accordance with the appropriate third-party billing regulations and/or standards. Assist with the development and implementation of pre- and post-audit education as needed.

Job Duties:

Utilizes auditing software to select and conduct random or focused audits of professional and hospital/facility inpatient and outpatient billing based on determined criteria. Conducts prospective and retrospective professional and inpatient and outpatient documentation audits to confirm compliance with documentation and billing rules and regulations set forth by the Centers for Medicare and Medicaid Services (CMS), Medicare/Medicaid Administrative Contractors (MACs), Medicare/Medicaid Recovery Audit Contractors (RACs), governmental audit entities, State regulations, and Institutional policies. Applies knowledge of professional, inpatient, and outpatient coding guidelines, and clinical documentation requirements to review billed services. Maintains a thorough understanding of CPT, ICD-10-CM, ICD-10-PCS, DRG, and HCPCS coding principles, governmental regulations, work plans, and third-party guidelines regarding documentation and/or billing compliance. Develops and maintains a close working relationship with the Billing Compliance team to ensure documentation issues, patterns, and/or trends are identified and addressed by prospective compliance education in a timely manner. Reviews providers' and coding personnel's coding accuracy and determines if the medical record is properly documented and if documentation supports the services billed. Performs Quality Assurance (QA) reviews of other auditors within the Office of Institutional Compliance as required. Assists with analysis of data/reports from compliance monitoring activities to help identify trends, issues, risk areas, and opportunities for education and/or process improvement. Prepares and presents reports as needed. Monitors compliance with documentation standards and keeps current with changes in coding guidelines, compliance, reimbursement, and other regulatory updates; researches, investigates, evaluates, and identifies opportunities for improvement. Has a good understanding of all clinical information systems and data flow across the continuum of care. Completes other job-related functions and special projects as assigned by the director. Performs other duties as required.

Salary Range:

Actual salary commensurate with experience.

Work Schedule:

Monday through Friday, 8 am to 5 pm, and as needed on occasion.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.