Coding Audit Specialist, Health Plan

Sanford Health • Remote WI, SD

2d • $22 - $35

About The Position

The Coding Audit Specialist conducts quality assurance activities to ensure the accuracy and integrity of risk adjustment data submitted to CMS and DHS. The role identifies coding deficiencies and provides management with analyses and tools to improve coding accuracy. It audits medical record documentation to determine appropriate diagnostic coding for services provided, following AMA CPT and ICD-9/ICD-10 guidelines, applicable CMS, HHS, and DHS BadgerCare Plus risk adjustment policies, and Hierarchical Condition Category (HCC) coding requirements.

Working with risk adjustment leadership, the specialist develops, implements, and monitors a continuous review program for Medicare Advantage risk adjustment scores and diagnosis documentation for ACA/Exchange and Medicaid/BadgerCare Plus members. The specialist reviews provider documentation and reported codes, determines whether documentation supports the codes, identifies uncoded or miscoded diagnoses, and summarizes audit outcomes clearly and logically.

Requirements

• High school diploma or equivalent.
• Demonstrated knowledge of anatomy, physiology, and medical terminology.
• Completion of courses in Current Procedural Terminology and ICD-9 and ICD-10 coding.
• Three years of experience in a health insurance, compliance, quality assurance, or auditing-related position.
• Experience with ICD-9, ICD-10, CPT, HCC, and HCPCS coding.
• Knowledge of CMS guidelines affecting Medicare Advantage, HHS-ACA, and DHS/BadgerCare Plus members as related to revenue management.
• Demonstrated knowledge of Word, Excel, and Access.
• Certified Professional Coder and/or Certified Risk Adjustment Coder certification from the American Academy of Professional Coders required within one year of hire.

Nice To Haves

• Associate degree in coding and/or a health-related field.

Responsibilities

• Develop, implement, and monitor a continuous review program with risk adjustment leadership for Medicare Advantage risk adjustment scores and ACA/Exchange and Medicaid/BadgerCare Plus member diagnosis documentation.
• Audit medical record documentation to verify correct code selection and identify uncoded or miscoded diagnoses for Medicare Advantage, ACA/Exchange, and BadgerCare Plus populations.
• Audit coding for evaluation and management visits and procedures documented by physicians, hospitals, and other providers across specialties and subspecialties, as it relates to HCC coding.
• Maintain knowledge of CPT, ICD-9, ICD-10, HCPCS, HCC coding, modifiers, documentation guidelines, CMS policy requirements, and other reimbursement guidelines.
• Compare provider documentation with the requirements of reported codes to verify that the documentation supports the codes.
• Determine and document audit outcomes, identifying correct or incorrect coding and presenting findings in a logical, concise summary.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED