Auditor Clinical Validation OPSP Coding Job Locations

US-Remote ID

2024-13397

Category Audit - Healthcare  

Position Type Full-Time Overview

This auditing role will focus on Coding and Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting, and services delivered.

Responsibilities

Audits Outpatient and Specialty Claims: Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims. * Draws on advanced coding expertise and industry knowledge to substantiate conclusions. * Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues. Effectively Utilizes Audit Tools * Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties. * Enters claim into Cotiviti system accurately and in accordance with standard procedures. * Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept. Meets or Exceeds Standards/Guidelines for Quality * Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation. Identifies New Claim Types * Identifies potential claims outside of the concept where additional recoveries may be available. * Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc. Recommends New Concepts and Processes * Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience. * Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction. * Evaluates information and draws logical conclusions. * Complete all responsibilities as outlined on annual Performance Plan. * Complete all special projects and other duties as assigned. * Must be able to perform duties with or without reasonable accommodation.

Qualifications

Education (required) * Associate or bachelor's degree Health Information Management (RHIA or RHIT) * Or equivalent combination of relative work experience.

Certifications/Licenses (required) * Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT

Experience * 5 to 7 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements. * Working knowledge of HIPAA Privacy and Security Rules, CMS security requirements and clinical medical record coding or auditing. * A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology. * Ability and desire to utilize base coding and clinical auditing knowledge to learn and become proficient in a variety of outpatient and specialty review types. * Adherence to official coding guide lines, coding clinic determinations and CMS and other... For full info follow application link.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities