Medical Auditor

ExactCare Pharmacy; United States; Remote; USD 70,000 - 110,000; Full time

Benefits offered by this job

Medical, dental, vision

401(k)

Paid time off

Short-term disability

Life insurance

Flexible spending account

Voluntary benefits

Paid holidays

Job summary

AnewHealth is a leading pharmacy care management company focused on complex chronic conditions nationwide. The Medical Auditor will review patient encounters to ensure complete documentation and accurate ICD-10 coding, while supporting compliance with third-party policies and accreditation standards.

The role is remote with the ability to assist clients across the United States, performing high-level audits, ensuring accuracy, and providing feedback for process improvements.

Qualifications

• Professional Medical Coder Certification required.
• One or more of: CCS, CPC, RHIT with ICD-10 CM coding experience.

Responsibilities

• Perform clinical validation audits and interpret documentation to ensure capture of patient conditions per coding guidelines.
• Conduct prospective, retrospective, and RADV audits as requested by client.
• Integrate coding principles in audit activities and educate on those principles.

Skills

CCS certification

CPC certification

RHIT certification

Education

CCS (AHIMA)

CPC

RHIT (ICD-10)

Tools

MS Word

Excel

PowerPoint

Job description

Medical Auditor

AnewHealth is one of the nation's leading pharmacy care management companies that specializes in caring for people with the most complex, chronic needs—wherever they call home. We enable better outcomes for patients and the healthcare organizations who support them. Established in 2023 through the combination of ExactCare and Tabula Rasa HealthCare, we provide a suite of solutions that includes comprehensive pharmacy services; full-service pharmacy benefit management; and specialized support services for Program of All-Inclusive Care for the Elderly. With over 1,400 team members, we care for more than 100,000 people across all 50 states.

This role will apply technical and specialized expertise to help risk adjusted organizations remain compliant while identifying opportunities for increased financial success.

This remote position performs highly technical and specialized functions. The primary function of the Medical Auditor is to perform a review of patient encounters to assess for completeness and accuracy of provider documentation, along with correct ICD-10 code assignment. Additionally, the Medical Auditor will work remotely, assisting clients to maintain compliance through completion of focused chart audits, ensuring compliance with established coding guidelines, third party reimbursement policies, regulations, and accreditation guidelines.

Responsibilities include:

• Perform clinical validation audits and interpretation of medical documentation to ensure capture of patient conditions in compliance with coding guideline
• Performs reviews for prospective audits, retrospective audits, and RADV audits when requested by client.
• Integrates coding principles in performance of medical audit activity and educates as needed on those principles
• Upon completion of medical record audit, compiles detailed findings and prepares client reports.
• Reviews medical record audit results with the client on a monthly or as needed basis.
• Provides feedback and process improvement recommendations to Client Service Liaison regarding assigned clients and participates in workgroups/committee meetings and process improvement solutions as required.
• Advises Client Service Liaison of possible trends in inappropriate utilization
• Maintains professional license and certifications. Attends training conferences and webinars, as necessary to keep abreast of latest trends in ICD-10 coding
• Reviews bulletins, newsletters and periodicals and attends workshops to stay abreast of current issues, trends and changes in the laws and regulations governing medical ICD-10 CM coding and documentation
• Understands and adheres to the Health Insurance Portability and Accountability Act (HIPAA) requirements
• Participates as requested in department meetings, client calls and annual performance evaluation
• Embody AnewHealth's Core Values in all communications and interactions.
• Other duties as assigned.

Qualifications:

• Required: Professional Medical Coder Certification, one or more of the following:
  • Certified Coding Specialist designation (CCS) issued by the American Health Information Management Association
  • Certified Professional Coder (CPC)
  • Technologist (RHIT) with 6 months experience coding ICD-10 CM
• Preferred:
  • CRC certification, CPMA

Experience:

• Experience in Clinical documentation improvement.
• Experience in Hierarchical Condition Categories (HCC).
• Knowledge of or experience in Medicare Advantage plans.
• Knowledge of or experience in managed health care systems, PACE or Medicare.
• Must have experience with MS Word, Excel, PowerPoint and comfortable with learning and becoming an expert on new and proprietary software.

This is a full-time position with an expectation to work an average of 40 hours per week and be available outside of normal business hours to meet customer expectations on an ad-hoc basis. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.

Travel may be required for special organization or department events, department team meetings, trade shows, conferences, and other client engagements.

AnewHealth offers a comprehensive benefit package for full-time employees that includes medical/dental/vision, flexible spending, company-paid life insurance and short-term disability as well as voluntary benefits, 401(k), Paid Time Off and paid holidays. Medical, dental and vision coverage are effective 1st of the month following date of hire.

AnewHealth provides equal employment opportunity to all qualified applicants regardless of race, color, religion, national origin, sex, sexual orientation, gender identity, age, disability, genetic information, or veteran status, or other legally protected classification in the state in which a person is seeking employment. Applicants are encouraged to confidentially self-identify when applying. Local applicants are encouraged to apply. We maintain a drug-free work environment. Applicants must be eligible to work in this country.