Medical Coding and Billing Auditor

Triple-S Management Corp.; Northern (KY); Hybrid; USD 65,000 - 95,000; Full time

Job summary

Triple-S Management Corp. is seeking a skilled coder/auditor to review medical records and coding data for accuracy and regulatory compliance.

The role collaborates with risk adjusters, billers, and providers to improve documentation and reimbursement processes. The ideal candidate will have a CPC certification and a minimum of two years of related experience, preferably in outpatient settings, with strong analytical and training abilities.

Qualifications

• Bachelor's degree required.
• Minimum of two years of related experience in outpatient setting.
• CPC - Certified Professional Coder or equivalent certification preferred.

Responsibilities

• Audit medical records, billing data and coding documentation for accuracy and compliance.
• Provide feedback, training and recommendations to clinicians and billers.
• Review and support correct coding to ensure proper reimbursement from insurers and government programs.
• Identify gaps and trends in documentation and escalate issues with providers and staff.
• Prepare reports and action plans based on analysis for management review.
• Stay current with coding standards and healthcare regulations; participate in training sessions.

Skills

Auditing

Medical Coding

Risk Adjustment

Regulatory Compliance

Training & Feedback

Communication

Education

Bachelor's Degree in Business Administration or Health

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

JOB SUMMARY

Responsible for auditing medical records, billing data, and coding documentation to identify discrepancies, errors, and potential areas of improvement. Review and evaluate medical coding to ensure accuracy, compliance with regulations, and adherence to organizational policies. Will work closely with risk adjusters, billers, healthcare providers, and compliance teams to provide feedback, training, and recommendations for process enhancements. Responsible for reviewing and supporting healthcare providers to correctly and completely
code healthcare claims, in order to comply with laws and regulations to obtain reimbursement from insurance companies and government healthcare programs, such as Medicare and Medicaid. Claim submitting as needed.

ESSENTIAL FUNCTIONS

• Evaluate and analyze medical records to ensure that all documentation is correctly codified in accordance with all Salus and Urgent Care centers contracted payers and industry guidelines.
• Finalize recommendations in medical records and submit changes into the system of record.
• Identify gaps and trends in the medical record’s documentation and refers for escalation process any issue found with theprovider, patient care coordinators and billers.
• Prepare reports, summaries and action plans based on the analysis performed and present it to management.
• Review and act on any assigned audit educational opportunities timely and provide training as necessary to educate over auditfindings to physicians and medical office staff, patient coordinator and billers.
• Understands, develops, tracks, monitors, and reports on key program performance metrics for coding initiatives.
• Conducting regular and random audits of coded medical records Pre and/or Post billing for CPT, HCPCS, ICD 10 and risk adjustments.
• Collaborate in the development of coding policies and procedures. Preparing detailed audit reports.
• Assure compliance by delivering quality services and meeting all contractual, state & federal legal and regulatory requirements.
• Provide any support requested by administration. May require some travel to any Salus/TSS/Urgent Care.
• Expected to stay up to date with changes in coding standards and healthcare regulations, participate in training sessions, and support the ongoing education of coding and provider staff.

EDUCATION

• Bachelor's Degree in Business Administration or Health

EXPERIENCE

Bachelors degree, preferably in Business Administration or Health related. Minimum of two (2) years of related experience, preferably in an outpatient setting.

LICENSES AND CERTIFICATIONS

• CPC - Certified Professional Coder

COMPETENCIES

• Action Oriented
• Manages Ambiguity

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.