Coding Compliance Auditor

POSITION SUMMARY

Audits medical records to ensure compliance with coding procedures and standards, based on CHG’s protocols, regulatory requirements (CMS, DHCS, DMHC), and American Medical Association (AMA). Reviews and provides processing recommendations on routes from Claims Disputes and Claims Department. Collaborates with CMO to review medical records to validate claim determinations. Identifies training needs for Claims and Provider Services department. Ensures compliance with coding, fee-schedule, and system changes. Works closely with department leadership to improve efficiencies, make recommendations that will support the departmental goals and provide resources and education to Claims and Provider Services Departments.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and Medi-Cal.

RESPONSIBILITIES

• Audits and reviews medical records to provide resolution on claim dispute routes and claim routes (emergency claims down coding, modifier payment reduction, modifier payment increases, medically unlikely edits (MUE), Virtual Examiner NCCI edits, implants with a payment greater than $10,000), and invoices.
• Works closely with CMO to review medical records to validate claim determinations, identify FWA through medical record review, and resolve pending dispute cases to meet compliance.
• Assist Claims, UM, Contracting, and IS Department with CPT, HCPCS, and ICD-10 related coding projects (contracts, reports, etc.).
• Ensures fee schedule updates are identified accordingly (PDPM, AB1629, Hospice rates, etc.).
• Make process related recommendations on medical coding changes to meet coding compliance.
• Assists with adjustment projects as it relates to coding, fee-schedule, or system updates.
• Provide research, and other support services to ensure observance with official coding policies, regulations, requirements, and standards.

• Through the review of provider disputes, identify training opportunities for the Claims team and Disputes team. Submit written recommendations to Claims Compliance Supervisor.
• Reviews literature and regulatory guidelines for claims processing updates including Medi-Cal, Medicare, and National Correct Coding Initiative (NCCI).
• Analyze NCCI coding software reports for accuracy.
• Audit disputes denial language (written determination) to ensure written explanation is clear, accurate, and appropriate.
• Maintain and update desktop procedures related to coding or fee schedule changes.
• Candidate must maintain credentials and be in good standing with credentialing organization.
• Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Requirements

Education:

• Certified Professional Medical Auditor
• Certified Professional Coder
• Bachelor’s Degree preferred.

Experience/Skills:

• A minimum of five years of experience in claims adjudication and medical record auditing.
• Strong knowledge of AB1455 regulatory requirements, CMS and Medi-Cal billing guidelines, CPT and ICD 10 coding, and medical terminology.
• Ability to read, analyze and interpret regulations and contract language.
• Excellent customer service skills.
• Good technical writing skills.
• Good judgment and problem-solving skills; team player; and ability to work independently.

Physical Requirements:

• Prolonged periods of sitting and frequent walking.
• May be required to work evenings and weekends.