Job Description Summary

The Coding & Compliance Auditor evaluates medical record documentation and coding accuracy, identifies opportunities for improvement, and designs and delivers coding education and training programs for clinical staff, coders and other key stakeholders. The Coding & Compliance Auditor monitors external regulatory and internal process changes and provides support to colleagues in adhering to Federal, State and local requirements.

Job Description

Job Responsibilities:

Establishes, implements, and maintains a formalized review process for coding compliance, including a formal review (audit) process.

Responsible for conducting both routine and targeted audits to ensure clinical documentation supports accurate CPT, HCPC’s, PCS and ICD-10-CM codes.
Perform prospective and retrospective audits to validate medical necessity and documentation supportive of code selection.
Analyzes data to identify deficiencies, prepare reports to deliver provider education specific to training needs identified during audit.
Develop and monitor follow-up audits and education as determined necessary to improve documentation quality.

Support all departments of the Health System with coding guidance:

Pertaining to compliance training / education as requested from providers and/or staff related to coding, billing and documentation in the inpatient, outpatient, professional, surgical and Home Health divisions of the Health System to ensure accuracy and support program objectives.
Designs training programs around compliant coding and billing from a regulatory standpoint for any new initiatives or programs affecting the Health System.
Evaluates vendor-training materials for its application or recommendation for use in educational programs.

Maintains:

Knowledge of all State and Federal regulatory changes that impact the Health System
Revises/modifies any instructional tools as necessary based on any changes to State and Federal regulatory changes to ensure guidance and training are accurate.
Assists in the development of follow-up mechanisms to ensure that knowledge and/or skills learned in the training are being applied on the job and have an impact on staff performance in meeting organizational goals.
Reports on program effectiveness and documents necessary changes.

Self Development:

Participates in professional societies or organizations relevant to ICD-9-CM, ICD-10-CM, PCS and CPT.
Maintains necessary licensure required for employment.

Administrative Duties:

Assists with administering programs as assigned.
Attends and participates in organization-wide committees as assigned.
Performs additional related duties as required.
Designs, develops and delivers education and training programs that meet the staff’s needs for compliant coding and billing.
Plans and develops curriculum in accordance with the organization’s strategic goals, mission and business strategies to improve employee performance leading to quality data and accuracy.

JOB REQUIREMENTS

Minimum Education - Preferred

Associates or Bachelor’s degree in Health Information Management.

Minimum Work Experience

Minimum 5 years acute care coding with demonstrated expertise in ICD-9-CM, ICD-10-CM, PCS and CPT coding.
Experience, preferred, in adult and continuing education, organizational development and training.

Required Certifications

CCA - Certified Coding Associate (AHIMA-American Health Information Management Assoc) or

CCS - Certified Coding Specialist (AHIMA-American Health Information Management Assoc) or

CCS-P - Certified Coding Specialist-Physican Based (AHIMA-American Health Information Management Assoc) or

CPC - Certified Professional Coder (AAPC-American Academy of Professional Coders) or

CPMA -Certified Professional Medical Auditor (AAPC-Academy of Professional Coders) or

RHIA - Registered Health Information Administrator (AHIMA-American Health Information Management Association)

Required additional Knowledge and Abilities:

Interact with constituents who have competing priorities and effectively communicate the importance of compliance in a respectful yet authoritative manner.