Company :

Job Description : 

GENERAL OVERVIEW:

Senior most coding auditor who evaluates medical records to determine the accuracy of coding, billing and documentation related to DRG, OPPS and outpatient claims. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, process changes and risk reduction. Provides guidance to System entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Interacts with external consultants regarding, billing, coding and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines.

ESSENTIAL RESPONSIBILITIES

• Audits and reports on the documentation, coding and billing performed at System entities. (25%)
• Reviews, develops and delivers training programs and educational materials which address deficiencies identified in the audits. (25%)
• Consults with management. Provides written 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. (20%)
• Maintains coding knowledge and billing regulations associated with DRGs, CPT coding, ICD diagnosis and procedures coding and changes in CMS regulations. (20%)
• Acts as mentor and subject matter expert for staff. (5%)
• Performs other duties as assigned or required. (5%)

QUALIFICATIONS

Minimum

• Bachelor’s Degree and Registered Health Information Administrator (RHIA) certification or ten (10) years’ experience in a medical record setting and one (1) of the following certifications from a certifying body must apply:

• 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 Hospital Outpatient (CPC-H), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA)
• Minimum of 7 years’ experience in hospital coding and auditing as well as experience in educational techniques and methods
• Must be proficient in Diagnosis Related Groups (DRGs), National Correct Coding Initiatives, ICD 10 Official Guidelines, Outpatient Prospective Payment System and Coding Clinic references
• Strong analytical and communication skills are required
• Knowledge of reimbursement systems and regulations pertaining to health information (HIPAA, CMS, etc.)
• Proficient writing skills, preparation of reports and training materials and presentation of clear and concise information (oral and written) are also required
• Ability to effectively communicate findings to staff as well as senior management and external regulatory agents
• Proficient in use of Microsoft Word, Excel and PowerPoint

Preferred

• Master’s Degree.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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