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