Coding Auditor Educator
Highmark Health
- Missouri
- Permanent
- Full-time
- Plans and \conducts audits and reports on the documentation, coding and billing performed at AHN entities. Reviews, develops and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements. Provides written audit guidance. Participates with management in the assessment of external audit findings and responds as needed. Attends meetings and interacts with management to resolve issues and provide advice on new programs. Provides guidance to system entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Determine appeal action, prepare appeal letter follow up and identify education issues. (20%)
- Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact and profitability. Conducts education/training or works with external resources to present final audit findings to department staff, physicians and appropriate individuals. (20%)
- Validates the ICD-CM, ICD-PCS, CPT and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements. Performs periodic claim form reviews to check code transfer accuracy from the abstracting system and the chargemaster. (10%)
- Is responsible for or works with external resources to create and monitor inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends and variations in the facilities frequently assigned DRG/APC groups. Once identified, evaluate the cases of the change or problems and takes appropriate steps to effect resolution. (10%)
- Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD-CM ICD-PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC. (10%)
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines. Assures compliance with the coding guidelines and regulatory requirements. (10%)
- Performs other duties as assigned or required including training/mentoring of new staff, performing audits and research related to special projects and providing coverage for coding manager(s). (10%)
- Depending on location provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology and disease processes as it relates to the DRG/APC and other clinical data quality management factors. With technical direction and assistance from management, designs and implements coder education program, continuing education programs and Medical Staff education programs. Establishes and monitors performance and maintains appropriate documentation thereof. (10%)
- Other duties as assigned.
- High school diploma / GED
- Certification from American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)
- AHIMA Credentials (Inpatient or Outpatient): Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS)
- AAPC Credentials (Outpatient): Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA)
- 5 years with hospital or physician coding and/or auditing, as well as, education techniques and methods. (Internal transfer and promotion candidates may have a minimum of 3 years experience)
- In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems. Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective payment system and Coding Clinic references. Current working knowledge of encoder, grouper, abstracting and other related software.
- Strong analytical and communication skills
- Associate's Degree
- 3 years with claims processing and data management
- Past auditing and strong education/training background in coding and reimbursement