Coding Auditor Educator

Highmark Health•PA, Working at Home - Pennsylvania, PA

1d•$28 - $44

About The Position

Performs internal, concurrent, prospective, and retrospective coding audits. Reviews medical records to evaluate the quality and accuracy of coding, billing, and documentation, including DRG and APC structure and assignments for CPT, HCPCS Level II, ICD diagnoses, and procedures. Reports findings verbally and in writing and communicates results to affected areas. Uses audit findings to develop education, training, process changes, risk-reduction measures, and reimbursement optimization for new and current coders. Collaborates with CDMP and compliance programs to improve documentation that supports compliant coding. Interacts with external consultants on billing, coding, and documentation, and evaluates their recommendations and teaching plans for consistency with federal and state requirements. Plans and conducts audits, develops audit reports and guidance, delivers training, and supports responses to external coding audits and appeals. Reviews coding systems, claims, case-mix information, and DRG/APC patterns to identify issues and support resolution. Depending on location, provides or arranges education for facility healthcare professionals on coding guidelines, documentation, medical terminology, disease processes, and related clinical data quality factors. May design and implement coder, continuing education, and medical staff education programs with management direction. The role also includes training and mentoring staff, special-project audits and research, and coverage for coding managers as needed. The position requires compliance with AHIMA Standards of Ethical Coding, corporate compliance guidelines, applicable regulations, HIPAA, information security policies, and the company Code of Business Conduct. Pay range is $28.19–$44.13; the posting does not specify the pay period.

Requirements

High school diploma or GED.
Certification from AAPC or AHIMA.
An AHIMA credential for inpatient or outpatient coding: RHIT or CCS; or an AAPC outpatient credential: CPC, COC, or CPMA.
Five years of hospital or physician coding and/or auditing experience, along with experience in education techniques and methods. Internal transfer and promotion candidates may qualify with a minimum of three years of experience.
In-depth knowledge of ICD-CM, ICD-PCS, and CPT/HCPCS coding systems.
Proficiency in DRG/APC structure, National Correct Coding Initiatives, ICD-CM/PCS Official Guidelines, the Outpatient Prospective Payment System, and Coding Clinic references.
Current working knowledge of encoder, grouper, abstracting, and other related software.
Strong analytical and communication skills.
Compliance with applicable federal and state laws and regulations, company policies and training requirements, HIPAA, and information security policies.

Nice To Haves

Associate's degree.
Three years of claims processing and data management experience.
Past auditing experience and a strong background in coding and reimbursement education and training.

Responsibilities

Plan and conduct audits of documentation, coding, and billing at AHN entities, and report findings.
Develop and deliver training programs and educational materials to address audit deficiencies; provide written audit guidance.
Work with management to assess external audit findings and prepare responses as needed.
Advise management and attend meetings to resolve issues and discuss new programs.
Provide guidance in response to external coding audits, including those conducted by Medicare Administrative Contractors, RAC, MIC, and ZPIC; determine appeal actions, prepare and follow up on appeal letters, and identify education needs.
Develop audit detail summaries, spreadsheets, and reports addressing coding, documentation, financial impact, and profitability.
Present final audit findings to department staff, physicians, and other appropriate individuals, directly or through external resources.
Validate ICD-CM, ICD-PCS, CPT, and HCPCS Level II codes and modifiers; identify missed secondary diagnoses and procedures; and verify compliance with DRG/APC structures and regulatory requirements.
Review claim forms periodically to verify code-transfer accuracy from abstracting systems and the chargemaster.
Create or monitor inpatient case-mix reports and reports on the top 25 assigned DRGs/APCs, identify patterns and variations, evaluate affected cases, and take appropriate steps to resolve issues.
Review and interpret medical information, classify diagnoses and procedures using payor-specific ICD-CM, ICD-PCS, and CPT codes, and calculate DRGs and APCs.
Follow AHIMA Standards of Ethical Coding, corporate compliance coding guidelines, coding guidelines, and regulatory requirements.
Train and mentor new staff, conduct audits and research for special projects, and provide coverage for coding managers as needed.
Depending on location, provide or arrange education for facility healthcare professionals on coding guidelines and practices, documentation techniques, medical terminology, disease processes, and related clinical data quality factors.
With management direction, design and implement coder, continuing education, and medical staff education programs; establish and monitor performance and maintain appropriate documentation.
Perform other duties as assigned or required.