About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Roles and Responsibilities:

 Auditing and reviewing medical documentation for appropriate ICD and CPT coding
and ensuring that codes tally with doctors’ diagnosis.
 Asking explanation from physicians when code assignments are not straightforward or
documentation in the record is inadequate, ambiguous, or unclear for coding purposes
 Ensuring compliance with medical coding policies and guidelines.
 Be updated about new coding rules as codes change from time to time.
 Collecting and distributing coding related information and billing issues.
 Exceptional Knowledge of medical terminology, anatomy, physiology, disease
processes, and pharmacology.
 Work as part of a team and achieve the team quality and productivity standards.

Required Expertise & Qualification:

 Life Science graduation or any equivalent graduation with Anatomy/Physiology as
main subjects
 3 to 5 years of work experience as a medical coder.
 Any one of the following coding certifications CPC, COC, CRC, CPCP from AAPC CCS,
CCSP, CCA from AHIMA
 Proficient computer skills.
 Excellent communication skills, both verbal and written.
 Strong people skills & Outstanding organizational skills.
 Ability to maintain the confidentiality of information.

EM IP OP MEDICAL CODING AUDITOR:

Job Summary

The Medical Coding Auditor (E/M, IP, OP) is responsible for performing comprehensive quality reviews of medical records to ensure that all documented services are captured accurately and in compliance with official guidelines. This role balances the clinical complexity of, the procedural precision of Outpatient APCs, and the regulatory nuances of E/M leveling. The auditor identifies areas of risk, provides educational feedback to coders and clinicians, and ensures the organization is prepared for external audits.

Key Responsibilities

1. E/M (Evaluation & Management) Auditing

• Leveling Validation: Audit professional and facility E/M codes (99202–99499) based on the 2021/2023 CMS/AMA guidelines, focusing on Medical Decision Making (MDM) or Time.
• Specialty E/M: Review complex E/M services including Critical Care, Observation, and Consultations.
• Modifier Accuracy: Ensure proper use of modifiers (e.g., -25, -57, -24) to prevent denials for bundled services.

2. Inpatient (IP) Auditing

• DRG Validation: Validate the Principal Diagnosis and the impact of CC/MCCs on the MS-DRG or APR-DRG assignment.
• ICD-10-PCS Review: Audit complex inpatient procedure codes (PCS) to ensure the correct root operation and approach were selected.
• Clinical Validation: Verify that high-acuity diagnoses (e.g., Malnutrition, Encephalopathy, Acute Kidney Injury) are clinically supported by the medical record.

3. Outpatient (OP) Auditing

• CPT/HCPCS Validation: Review outpatient surgery (ASC), Emergency Department, and clinic visits for accurate CPT/HCPCS code selection.
• APC & OCE Edits: Ensure claims comply with the Outpatient Prospective Payment System (OPPS) and pass Outpatient Code Editor (OCE) and NCCI edits.
• Medical Necessity: Verify that ICD-10-CM codes support the medical necessity of the procedures performed (LCD/NCD compliance).

4. Quality Reporting & Education

• Reporting: Generate detailed audit reports identifying accuracy rates, financial impact, and "missed opportunities."
• Education: Lead "1-on-1" or group training sessions for coders and physicians to correct systemic errors.
• Query Oversight: Audit the physician query process to ensure queries are compliant and clinically appropriate.

Qualifications & Requirements

• Experience: 5–7 years of multi-specialty coding experience, with at least 3 years specifically in a formal auditing role covering E/M, IP, and OP.
• Certifications (Dual-Certification highly preferred):
  • CCS (Certified Coding Specialist) - Required for Inpatient/Facility.
  • CPC or CCS-P - Required for Professional/E/M.
  • CPMA (Certified Professional Medical Auditor) - Mandatory for most high-level auditor roles.
• Education: Bachelor’s or Associate’s degree IN LIFE SCIENCES.

Technical Skills

• E/M Mastery: Expert knowledge of the 1995/1997 (where applicable) and the current 2021/2023 E/M guidelines.
• PCS Logic: Deep understanding of the 7-character ICD-10-PCS code structure.
• Regulatory Knowledge: Expert-level understanding of NCCI edits, MUEs, OIG Work Plans, and CMS IOMs.
• Software Proficiency:
  • Encoders: 3M 360 (Encompass), Optum.
  • EHRs: Epic (ASAP, Stork, Radiant, OpTime), Cerner, or Allscripts.
  • Audit Tools: MDaudit, RevPoint, or similar platforms.

Soft Skills

• Diplomacy: Ability to deliver audit findings to physicians and senior coders without creating conflict.
• Analytical Rigor: Ability to find "the needle in the haystack"—identifying small documentation gaps that could lead to large financial recoupments.
• Technical Writing: Ability to draft clear, concise audit summaries and clinical appeal letters.

Key Performance Indicators (KPIs)

• Audit Throughput: Completing a set number of charts per month (e.g., 50 IP, 100 OP, and 100 E/M).
• Accuracy Target: Maintain a personal audit accuracy rate of 96% or higher.
• Organizational Improvement: Demonstrating a month-over-month decrease in coder error rates following educational sessions.
• Appeal Success Rate: The percentage of defended denials that are successfully overturned due to the auditor's clinical/coding justification.

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.