Coding And Compliance Auditor-Virginia

Innovage Richmond , VA 23234

Posted 4 months ago

Job Summary

The Coding and Compliance Auditor is responsible for performing audits of electronic health records, ensuring that all assigned ICD-9-10-CM or MS-DRG codes are supported by proper clinical documentation. This role will also be responsible for developing an educational program to support providers on coding accuracy, documentation improvement and drive revenue analysis.

Essential Functions and Work Responsibilities

Functional Category: Compliance

Estimated Percent of time Spent -85%

  • Maintain performance and quality by coordinating and conducting ongoing audits of physicians and mid-level providers' medical records to ensure that submitted ICD-9-10-CM and MS-DRG codes are fully supported by the clinical documentation.

  • Work with Sr. Coding/ Compliance Analyst and management teams to report on audit findings and support process improvement.

  • Abstract ICD-9-10-CM codes supported by provider documentation to the highest level of specificity possible. Ability to abstract these codes from hospital claims data and outpatient providers and specialists.

  • 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 projected reimbursement based on analysis of documentation and ICD-9-10-CM codes submitted in the RAPS files.

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

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

Functional Category: Training and Provider Education

Estimated Percent of time Spent 15%

  • Training of functions and services related to the primary care providers' coding and clinical documentation.

  • Tracking and reporting findings of chart audits and clinical documentation improvement (CDI) opportunities to providers in order to maximize the coding of ongoing risk adjusted conditions.

  • Supporting ongoing audit and query process to ensure that any amendment occurs in a timely and compliant manner.

  • Reinforce Risk Adjustment and HCC basic training in conjunction with the Organizational Development and Talent Management staff.

Travel Requirements


  • Travel may be required.

  • Overnight travel out of state.

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 CMC, CPC, CCS, CCS-P, or COC certification, 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-9-10-CM diagnosis and Current Procedure Terminology (CPT) codes, (AMA CPT, and CMS HCPCS codes); at least two years of continuous HCC/Risk Adjustment Coding and auditing experience

  • Extensive experience in a Physician practice.

  • Production driven coding experience needed.

  • Experience working in a remote setting.

  • Proficient understanding of the National Correct Coding initiative Edits (NCCI), ICD-9-10-CM Official Guidelines for Coding and Reporting, and coding clinic.

  • Working knowledge of laws, guidelines, regulations and resources including but not limited to HIPPA, CMS, OIG, OSHAPD, DHS, and Uniform Health Care Information Act.

  • Knowledge of Anatomy, Physiology and Medical Terminology.

  • Must possess working knowledge of excel spreadsheets at basics- intermediate skill level.

  • Skilled with hands-on experience in multiple EMR applications.


Licensure, Certification, Registration or Designation

  • Certified Risk Adjustment Coder (CRC).

  • Certified Professional Medical Auditor (CPMA).

  • MS-DRG Coding Knowledge & Experience.

  • Certified Documentation Improvement Practitioner (CDIP).

  • Associate's degree in related field or equivalent of 5 years direct coding experience.


  • This is a full time, mostly remote position with a requirement to provide onsite provider education at least twice a month or as needed at the designated center (s).
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Coding And Compliance Auditor-Virginia