Outpatient

Omega Healthcare Solutions•Boca Raton, FL

58d•$39 - $50

About The Position

This role involves conducting quality audits and providing education to coding staff, physicians, and other healthcare professionals. The primary focus is on ensuring the accuracy and compliance of medical record coding and clinical documentation. The position requires a strong understanding of clinical and coding principles, as well as excellent analytical and communication skills.

Requirements

Strong understanding of disease processes, clinical conditions, and medical terminology.
Familiarity with ICD-10-CM/PCS, CPT, and other relevant coding systems.
Experience in clinical documentation integrity, including chart review and query writing.
Ability to analyze data, identify trends, and make recommendations for improvement.
Excellent written and verbal communication skills to effectively communicate with various healthcare professionals.
Experience in auditing facility inpatient cases.
Experienced in Word and Excel.

Nice To Haves

Auditing outpatient cases is a plus.
CDI credential is a plus.

Responsibilities

Conduct initial quality audits for assigned coding staff during onboarding for new projects/client assignments.
Provide education to staff based on initial quality audit findings.
Review medical records for accuracy of coding and data quality, including CDI audit reviews.
Review medical records, including clinical notes, lab results, and other diagnostic information, to ensure documentation accurately reflects diagnoses, severity of illness, and risk of mortality.
Ensure documentation complies with regulatory requirements, coding guidelines, and payer rules.
Identify missed documentation opportunities, inconsistencies, and areas where documentation can be more specific or clarified.
Evaluate the appropriateness of queries issued to physicians, ensuring they are supported by clinical evidence and aligned with coding guidelines.
Analyze data related to CDI performance, identify trends, and report findings to leadership.
Provide education and training to CDI staff, physicians, and other healthcare professionals on documentation best practices, coding guidelines, and regulatory requirements.
Audit inpatient/observation cases for assigned ICD-10-CM and ICD-10 PCS codes, discharge disposition, POA indicators, APR-DRG, MS-DRG, SOI, and ROM assignment, and appropriateness of queries.
Audit outpatient cases (ER, SDS, Ancillary) for assigned ICD-10-CM and ICD-10 PCS codes, CPT codes, modifier use and assignment, and APC assignment.