Coding And Compliance Auditor - PA

Innovage Philadelphia , PA 19107

Posted 4 months ago

Job Summary

The Coding and Compliance Auditor is responsible for auditing electronic health records to review documentation and determine whether it substantiates the codes assigned (ICD-9-10CM/ MS-DRG/HCC). This role will be responsible for assisting in developing and supporting an education program to support providers on coding accuracy and documentation improvement; and drive revenue analysis while incorporating findings into a meaningful training program for all providers and staff.

Essential Functions and Work Responsibilities

Functional Category: Compliance

Estimated Percent of time Spent -85%

  • Conducts and coordinating ongoing audits of physician and mid-level provider documentation in the electronic health records to assure that submitted ICD 9/10 codes are fully supported by the documentation. Works with Sr. Coding and Compliance Analyst and other management to report on audit findings and support process improvement to ensure quality

  • Abstract ICD 9/10 codes supported by provider documentation to the highest level of specificity possible. Also be able to abstract these codes from claims data from hospital and outpatient specialist providers.

  • Ability to analyze abstracted codes against documentation to determine if highest level of coding specificity has been achieved.

  • Analyze, audit and reconcile risk adjusted Medicare PACE revenue to expected reimbursement based on analysis of documentation and ICD 9/10 codes submitted in the RAPS files

  • In conjunction with Sr. Coding and Compliance Analyst, ensures compliance with CMS regulations surrounding the RAPS submission process.

  • Support of any ongoing programs that minimizes organizational risk in the event of a Risk Adjustment Data Validation Audit (RADV audit).

Functional Category: Training and Provider Education

Estimated Percent of time Spent 15%

  • Actively involved in training of all functions and services related to primary care provider documentation and coding

  • Track and report findings of chart audits and opportunities to improve documentation and coding back to providers and staff

  • Support ongoing audit system to assure that improved documentation and coding occurs in a timely manner.

  • In conjunction with Organizational Development and Talent Management staff, t support of HCC basics training to be included with new provider competency assessment as well as ongoing primary care provider competency assessment.

Job Qualifications


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions



  • High School diploma or equivalent

Licensure, Certification, Registration or Designation

  • Requires state issued driver's license, personal transportation, good driving record and auto insurance as required by law

Work Experience and Qualifications

  • Minimum of three years of experience in assigning ICD-9-10CM diagnosis and codes procedure codes, (AMA CPT, and CMS HCPCS codes); extensive experience in a Physician practice; data analysis or equivalent combination of education and experience.

  • Proficient understanding of the medical Severity Diagnosis-Related Groups (MS-DRG), National Correct Coding initiative Edits (NCCI), ICD-9-CM & ICD-10CM Official Guidelines for Coding and Reporting, and coding clinic.

  • In-depth knowledge of laws and regulations pertaining to Health Information Management (e.g., TJC, HIPPA, CMS, OSHAPD, DHS, and Uniform Health Care Information ACT) required.

  • Knowledge with Anatomy, Physiology and Medical Terminology.

Licensure, Certification, Registration or Designation

  • Certified Professional Coder (CPC)


Licensure, Certification, Registration or Designation

  • Certified Risk Adjustment Coder (CRC)
  • Bachelor's degree in related field
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Coding And Compliance Auditor - PA