Outpatient Medical Documentation Auditor - Full-time, Remote

This is a remote position.

Job Summary:

The Medical Documentation Auditor ensures accurate and complete documentation through compliance and encounter audits and clinician feedback. Provides documentation feedback to clinicians from E&M, CPT, and ICD9 audits conducted using all state/federal and third-party payor regulatory standards for outpatient groups.

Essential Responsibilities:

Core Audit Responsibilities:

Conduct concurrent and retrospective audits of documentation supporting E/M, CPT, and ICD9 codes assigned by clinical staff.

Research correct coding practices in relation to applicable rules, regulations, and coding conventions for billing to determine compliance with Federal, State, and third-party payor regulations.

Review audit findings with individual physicians, making suggestions for documentation improvements.

Provide feedback to clinicians based on Federal and State government billing and coding guidelines.

Plan, schedule, and perform comprehensive chart audits to identify operational and regulatory issues related to coding, documentation, and compliance requirements.

Ensure complete and accurate data capture in compliance with Federal and State requirements.

Design and implement methodologies to ensure accurate and complete E&M, CPT, and ICD9 coding audits.

Provide technical expertise to leadership to identify and resolve coding and chart documentation problems impacting the accuracy and consistency of coded data.

Work with Trainers to address operational processes that hinder encounter data capture.

Enter audit results into audit tools to support quality assurance processes, analysis, and training activities.

Review analytical data and audit findings to identify coding trends and other risk areas and recommend appropriate actions.

Conduct quality assurance reviews and collaborate in the development and execution of audit and training plans.

Assist in developing and implementing policies and procedures to ensure compliance with Federal, State, and other regulatory requirements.

Requirements

Qualifications:

Minimum three (3) years CPT, ICD9, and E&M Coding experience.

Bachelor's degree in business administration, health care, public health, finance, business medical records technology, or four (4) years of experience in a related field.

High School Diploma or General Education Development (GED) required.

Certification as a Certified Coding Specialist, Certified Professional Coder - Hospital Outpatient, Registered Health Information Administrator, Registered Health Information Technician, or Certified Professional Coder.

Proficient in the use of PC applications such as MS Word, Excel, Access, and PowerPoint.

Experience conducting Medical Record audits and interpreting and applying Federal and State regulations, coding, and billing requirements.

Comprehensive knowledge of medical diagnostic and procedural terminology.

Ability to provide constructive and sensitive feedback to providers and leadership regarding federal and state coding, medical documentation, and compliance guidelines.

Ability to work with and maintain confidentiality of physician, patient, patient account, and personnel data.

Knowledge of outpatient coding practices.

Strong interpersonal, written, verbal, and presentation skills.

Ability to work independently with minimal supervision, prioritize workload, and meet deadlines.

Ability to read and interpret medical data.

Willingness to be flexible depending upon department and/or physician schedule needs.

Experience using electronic health record systems and web-based applications preferred.

Originally posted on Himalayas