Medical Coding Auditor

South Florida Community Care Network LLC•Sunrise, FL

16h•Hybrid

About The Position

The Medical Coding Auditor conducts audits to provide investigative support related to potential fraud, waste, abuse and/or overpayment. Through pre and post payment medical records review and appeal records review, the Medical Coding Auditor ensures appropriate coding on claims paid and maintains compliance documentation of any fraud, waste or abuse identified based on coding guidelines, coverage policies and regulatory and contract requirements.

Requirements

Medical Coder certification from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) required.
Knowledge of Medicaid rules, claims processing, medical terminology and coding principles and practices.
Knowledge of auditing, investigation, and research.
Knowledge of word processing software, spreadsheet software, and internet software.
Manage time efficiently and follow through on duties to completion
Written and verbal communication skills.
Ability to organize and prioritize work with minimum supervision.
Detail oriented.
Ability to perform math calculations.
Analytical and critical thinking skills.
Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions.

Nice To Haves

Prior experience in Medicaid claims role and/or post payment medical coding auditor role preferred.

Responsibilities

Maintains a caseload of audit reviews and a caseload of appeals reviews, ensuring movement and timely action taken. Documents time spent through software used.
Performs pre and post payment medical record review audits of claims payments to identify potential fraud, waste, abuse and/or overpayment based on contract/regulatory requirements, coding guidelines, and coverage policies.
Performs reviews of appeal records received based on contract/regulatory requirements, coding guidelines, and coverage policies, prepares review summary for presentation to the appeals committee, and presents appeal review to the appeals committee. Generates appeal committee determination notice, sends to provider, and tracks for response.
Generates statistically valid random samples through software used. Generates audit notice with sample/attestation, sends to provider, and tracks for provider response.
Monitors the CCP fax and CCP.SIU inboxes for receipt of medical records.
Completes and maintains detailed documentation of audits including but not limited to coding guidelines reviewed, coverage policy documentation, decision methodology, and monetary discrepancies identified.
Notifies the provider of audit findings, including but not limited to overpayment, education, and no issues identified.
Responsible for reviewing audit and appeal records for potential fraud, waste or abuse, documenting any FWA findings for presentation to Manager, Compliance for further investigation.
Documents all audit steps in the case in the software used.
Prepares written reports or trending data related to findings and facilitates timely turnaround of audit results.
Prepares written summaries of audit results for purposes of reporting potential fraud, waste, abuse and/or overpayment.
Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner.
Identifies potential provider fraud through review of claims data, complaint referrals, and application of rules, healthcare coding practices, and fraud detection software.
Reviews provider billing practices to investigate claims data and compliance with State and Federal laws.
Analyzes provider data and identifies erroneous or questionable billing practices.
Interprets state and federal policies, Florida Medicaid, Children’s Health Insurance Program, Marketplace, and contract requirements.
Determines and calculates overpayment/underpayment, appropriately documents and participates in steps to remediate.
Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.
Performs all other duties as assigned.