Medical Auditor

AnewHealth•NJ - Remote, NJ

7d•Remote

About The Position

AnewHealth is a pharmacy care management company focused on people with complex, chronic needs. Formed in 2023 through the combination of ExactCare and Tabula Rasa HealthCare, the company offers comprehensive pharmacy services, pharmacy benefit management, and specialized support for Programs of All-Inclusive Care for the Elderly. AnewHealth has more than 1,400 team members and serves over 100,000 people across all 50 states. The Medical Auditor performs technical, specialized reviews of patient encounters to assess the completeness and accuracy of provider documentation and ICD-10 code assignment. This remote role supports clients with compliance through focused chart audits and ensures adherence to coding guidelines, reimbursement policies, regulations, and accreditation guidelines. The position works an average of 40 hours per week and may require availability outside normal business hours on an ad-hoc basis. Travel may be required for organizational or department events and client engagements.

Requirements

Professional medical coder certification: Certified Coding Specialist (CCS) issued by the American Health Information Management Association, Certified Professional Coder (CPC), or Registered Health Information Technician (RHIT) with six months of ICD-10 CM coding experience.
Experience in clinical documentation improvement.
Experience with Hierarchical Condition Categories (HCC).
Knowledge of or experience with Medicare Advantage plans.
Knowledge of or experience with managed health care systems, PACE, or Medicare.
Experience with MS Word, Excel, and PowerPoint, and comfort learning and becoming proficient in new proprietary software.
Maintain the professional license and certifications applicable to the role.
Meet the physical demands of an administrative position, including hearing, seeing, sitting, standing, talking, and walking.
Be able to commute to multiple site locations within the assigned territory.
Be available to work extended hours as needed and outside normal business hours on an ad-hoc basis to meet customer expectations.

Nice To Haves

CRC certification.
CPMA certification.

Responsibilities

Perform clinical validation audits and interpret medical documentation to ensure patient conditions are captured in compliance with coding guidelines.
Conduct prospective, retrospective, and RADV audits when requested by clients.
Apply coding principles during medical audits and provide education on those principles as needed.
Compile detailed findings and prepare client reports after completing medical record audits.
Review medical record audit results with clients monthly or as needed.
Provide feedback and process improvement recommendations to the Client Service Liaison, participate in workgroups and committee meetings, and contribute to process improvement solutions as required.
Advise the Client Service Liaison of possible trends in inappropriate utilization.
Maintain professional licenses and certifications, and attend training conferences and webinars as necessary to stay current with ICD-10 coding trends.
Review bulletins, newsletters, and periodicals and attend workshops to stay informed about issues, trends, and changes in laws and regulations governing medical ICD-10 CM coding and documentation.
Understand and adhere to HIPAA requirements.
Participate as requested in department meetings, client calls, and annual performance evaluations.
Embody AnewHealth’s Core Values in communications and interactions.
Perform other duties as assigned.