Coding Auditor

Facility: VIRTUAL-GA

Job Summary:

Under direction of the Manager of Coding Assurance/Compliance, reviews chart documentation to ensure coders have appropriate coding and DRG assignment, discharge disposition, admit and discharge dates and reimbursement. Educate staff when errors are identified. Coordinates payment corrections with the assistance of the Billing and Revenue Cycle team:
Audit hospital and/or physician medical records and charges to ensure compliance with coding and regulatory standards.
Conduct medical record reviews to ensure accurate, ethical documentation, coding, charging and billing practices.
Support and provide coding and compliance training to coding staff, physicians, clinical personnel, billing, and/or other hospital staff.
Establish effective communication with coding staff, physicians, clinical staff, and/or hospital staff to address documentation, coding, and reimbursement issues.
Educate coding staff, physicians, clinical staff, and/or hospital staff on appropriate documentation as required by medical review and governmental agencies.
Develop written policies promoting WellStar's commitment to compliance and specific areas of potential fraud and abuse.
Use knowledge of coding and compliance guidelines to identify potential billing / reimbursement issues.
Participate in special audits as instructed.
Work as a team member within Coding Assurance and all other departments.
Ability to work remotely and independently with self-driven focus on job completion.
Document work processes as required.
Perform other duties as assigned.

Core Responsibilities and Essential Functions:

DRG Validation, RAC and Government Entity Reviews, Appeals, Overpayment Review Functions
Investigate overpayment and underpayment issues through DRG reviews, responses to RAC and other governmental audit requests, internally generated audit requests, Epic Work Queue assignments:
* Conduct data sampling, auditing, and reporting on all reviews associated with the Annual IP Coding Assurance Audit plan and as otherwise directed to the level of detail required;
* Participate in Epic Work Queue assignments as necessary to ensure compliance with governmental and internal regulations;
* Research official guidelines to plan scope of focused reviews;
* Participate and lead audits with focus on inpatient hospital ICD9-CM, ICD-10-CM / PCS, some CPT4 coding as well as National and Local Coverage Determinations, OIG Work plan, and any other federal/state regulations;
* Communicate trends and audit findings with the respective hospital departments and educate as appropriate;
* Prepare Findings and Executive Summary reports to distribute to coding and compliance leadership
* Prepare and distribute audit findings worksheets to coders;
* Engage in cooperative education with the coders when discussing audit findings;
* Assist in data warehousing, data reporting, and data integrity tasks of audit data housed in Compliance dbs and spreadsheets;
* Direct resubmission of claims and help prepare disclosures as necessary.
Benchmark comparisons and identification of trends and errors in coded data
* Review data analytics;
* Identify / track trends and errors to identify overpayments or revenue enhancement opportunities;
* Trend and analyze denials, provide feedback and education to all entities ;
* Identify, find solution, communicate solution with both external and internal customers as required utilizing Findings and Executive Summary formats;
* Distribution and analysis of reports to relevant, affected departments;
* Provide and participate in error resolution to correct variances in coding and/or charge practices;
* Assist with the implementation of new processes as needed to assure error resolution.
Provide education and support
* Review CMS regulations and official coding guidance to stay abreast of coding/billing regulatory changes;
* Summarize National/Local Coverage Determinations;
* Presentations (Develop and present coding/compliance education material);
* Provide denial/appeal follow-up;
* Provide post review follow-up education with WellStar employees, management and physicians;
* Provide education on new releases from Medicare and Medicaid;
* Answer compliance/documentation/coding/billing questions via e-mail.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelor or Associate-level degree in Health Information Management, Business, or other health care related field preferred.

• An Associate's degree OR a combination of 5 years comparable experience with hospital coding, billing, and reimbursement experience may be substituted for an Associate's degree.

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Reg Health Information Admin (RHIA), or

  Reg Health Information Tech (RHIT), or

  Cert Coding Specialist (CCS), or

  Cert Professional Coder-Hospital OP, (CPC-H) or

  Certified Coding Specialist – Physician Based (CCS-P)

Required Minimum Experience:

5 years inpatient coding experience and 1-2 years hospital-based outpatient services coding experience required.

Additional one year inpatient audit experience preferred.

Required Minimum Skills:

Excellent communication, organization, and educational skills.
Extensive knowledge of medical terminology, ICD-10-CM and ICD-10-PCS coding (as well as ICD-9-CM), CPT-4 procedural coding (including Level II HCPCS), and all coding and billing guidelines.
Hospital billing experience with focus on government payors.
Extensive experience with (electronic) medical record chart review and/or extraction, hospital billing.
Extensive experience with Medicare, Medicaid, and reimbursement rules and regulations.
Experience with management information systems and medical software.
Competence in Microsoft Word and Excel software in a Windows environment (Experience with Microsoft Access Is a plus).