Outpatient Facility Coding Compliance Auditor
About The Position
The Outpatient Facility Coding Compliance Auditor performs audits of outpatient facility (OPPS) coding to ensure accurate assignment of ICD-10-CM diagnoses, CPT/HCPCS codes, modifiers, and facility E/M levels using ACEP or client-specific guidelines. The role reviews coding against medical record documentation and established guidelines, ensuring compliance with applicable laws, regulations, and billing standards, and communicates findings to stakeholders. The Auditor analyzes audit outcomes to identify trends, root causes, and improvement opportunities, and assesses the effectiveness of corrective actions. As part of the Compliance Workplan, the role also participates in quality assurance coding oversight, conducts independent reviews, and supports organizational compliance initiatives. This is a remote role available from anywhere within the U.S.
Requirements
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Outpatient Coder (COC).
- At least 5 years of outpatient facility coding experience, including NCCI/OCE billing edits related to outpatient services coding and billing, ICD-10-CM and CPT (including CPT-4), and ACEP Facility or similar Facility E/M matrix guidelines for outpatient facility code assignment.
- At least 5 years of outpatient facility audit experience, including surgery, observation, and emergency department audits.
- Strong industry knowledge of Medicare regulations and payment policies, including OPPS.
Nice To Haves
- Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Professional Medical Auditor (CPMA).
- Demonstrated ability to perform independent, autonomous audit and coding review functions.
- Strong professional oral and written communication skills.
- Ability to prioritize and manage multiple assignments, spreadsheets, documents, and reports.
- Proven time management skills with consistent follow-through to completion.
- Proficiency with Microsoft Excel, Teams, PowerPoint, Word, and Outlook.
Responsibilities
- Perform coding compliance and quality audits in support of Optum Insight Provider’s Compliance Program and client expectations.
- Independently analyze and interpret clinical documentation from medical records.
- Validate outpatient facility coding accuracy, including E/M services, procedures, and modifiers.
- Identify audit findings, calculate billing error rates, and perform root cause analysis to determine drivers of non-compliance.
- Assess the adequacy and effectiveness of corrective action plans and provide follow-up validation as appropriate.
- Document audit findings and communicate results to the appropriate audience.
- Prepare written audit analysis and summary reports covering compliance risk, trends, and recommended corrective actions.
- Conduct ad hoc coding and billing audits as requested.
- Provide compliance oversight of QA audit activities, ensuring consistency and adherence to established standards.
- Audit vendor coders and auditors, including offshore staff.
- Monitor industry trends, regulatory updates, and government audit activities to identify potential coding and billing risks.
- Stay current with applicable coding, billing, and regulatory guidelines.
- Research, develop, and present targeted education based on individual, team, and systemic audit findings.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution, subject to eligibility requirements.
- Career development opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
