Clinical Coding Auditor

This is a fully remote position, open to applicants in Texas.

📋 Description

• Ensures the correctness of assigned ICD-10-CM and PCS codes along with DRG grouping.

• Confirms the accuracy of assigned HCPCS, CPT-4, and APC grouping for secondary diagnoses and procedures.

• Validates the assignment of medically necessary narrative diagnoses as required for specific inpatient medical coverage policies, including communication with clinical staff and/or physicians.

• Evaluates the usage and quality of coding queries; reports any non-compliance with regulatory and/or departmental standards.

• Monitors trends and patterns among coders to identify educational opportunities and/or areas for improvement in physician and clinical documentation.

• Maintains a DRG change accuracy rate of 95%.

• Assists the CCDI department by serving as Subject Matter Experts (SME) in ICD-10-CM and PCS reporting for the Coding Reimbursement & Audit team.

• Accurately utilizes departmental audit databases and/or software to ensure robust and precise audit data to reflect coded data accuracy.

• Prepares comprehensive reports using Excel, Excel pivot tables, and/or other provided software; continuously enhances trend identification and capture for optimal reporting.

• Supplies ad hoc and/or additional data to assist in identifying opportunities and providing feedback to leadership.

• Identifies and communicates opportunities for process enhancements.

• Captures meeting minutes, follow-ups, and action plans as needed based on audit scope.

• Suggests improvements and implements methods and procedures for coder and physician education and training; creates and shares tips and educational resources to foster department collaboration and efficiency.

• Provides necessary data to aid in the identification and development of actions.

• Updates and develops team policies and procedures for process optimization; recommends practices to uphold standards for accurate coding.

• Consistently achieves team KPI goals to support department and system revenue and quality objectives.

• Adjusts to changes in workload and volumes, collaborating with the team and/or lead to ensure optimal coverage.

• Verifies, researches, and reviews codes, charges, and reimbursements on patient accounts and denials or service lines.

• Completes daily productivity tracking; initiates discussions among Analysts to ensure collaborative, consistent, and accurate decision-making.

• Resolves ITS issues affecting work through collaborative communication with team members, vendors, informaticists, and/or IT as necessary.

• Maintains regular contact with the manager and seeks consultation and guidance when needed.

• Engages in personal annual performance evaluations, providing opportunities for growth and development.

• Participates in committee work and cross-functional teams as directed by department leadership.

• Adheres to the Standards of Ethical Coding set by AHIMA and complies with Official Coding Guidelines; reviews and applies directives from the AHA Coding Clinic, CPT Assistant publication, and other approved resources.

• Keeps certifications current with CE credits and actively pursues knowledge and participation in HFMA, AAPC, and AHIMA organizations.

• Stays informed about regulatory requirements and payer coverage determinations, demonstrating initiative in identifying areas needing further research.

• Completes all required training and education for the department and system hospitals according to schedule; maintains all necessary certifications and continuing education requirements.

• Meets deadlines for audits, projects, and tasks.

• Acts as a subject matter expert in documentation, ICD-10-CM and PCS coding, with proficiency in CPT-4, HCPCS, and modifier assignment.

⛳️ Requirements

• Bachelor's Degree in Health Information or a related field is preferred.

• Associate's Degree in Health Information or a related field is required.

• High School Diploma or Equivalent; 5 years of acute care and/or relevant experience may be substituted for the degree requirement.

• 5 years of experience in acute care inpatient or CPT surgical level coding is required.

• 1 year of experience performing coding and documentation audits is preferred.

• RHIA - Registered Health Information Administrator certification is required within 12 months.

• RHIT - Registered Health Information Technician certification is required within 12 months.

• CCS - Certified Coding Specialist certification is required within 12 months.

• COC - Certified Outpatient Coder certification is required within 12 months.

• Comprehensive knowledge of ICD 10-CM, PCS, and CPT coding.

• Expertise in coding conventions and automated encoding, including knowledge management of NCCI/OCE billing edits.

• Experienced in APC and DRG methodologies and the regulatory/payer requirements associated with coding.

• Ability to interpret and apply coding and regulatory policies to coding practices and record review processes.

• Must demonstrate effective time management and organizational skills.

🏝️ Benefits

• Health insurance.

• Professional development opportunities.

• Occasional travel for educational purposes and meetings.