Coding Audit Specialist, Health Plan

This is a fully remote position, open to applicants in South Dakota, +1 more state.

📋 Description

• Perform quality assurance tasks to verify the accuracy and reliability of risk adjustment data submitted to CMS and DHS.

• Detect coding errors and provide management with detailed analyses of results and tools to enhance coding precision.

• Create, execute, and oversee an ongoing monitoring program for Medicare Advantage, ACA/Exchange, and Medicaid/BadgerCare Plus diagnosis documentation.

• Review medical record documentation to ensure correct, uncoded, or incorrectly coded diagnoses.

• Assess coding for visits and procedures recorded by healthcare professionals, hospitals, and other providers across various specialties and subspecialties.

• Stay informed about CPT, ICD-9, ICD-10, HCPCS, HCC coding, modifiers, documentation standards, CMS regulations, and reimbursement policies.

• Evaluate provider documentation against the requirements for reported codes.

• Develop audit results and present clear, logical summaries of accurate and inaccurate coding findings.

⛳️ Requirements

• A high school diploma or equivalent is required.

• Proven understanding of anatomy/physiology and medical terminology.

• Completion of courses in Current Procedural Terminology and ICD-9 and ICD-10 coding is necessary.

• A minimum of three years of experience in a health insurance, compliance, quality assurance, or auditing-related role is required.

• Experience in ICD-9, ICD-10, CPT, HCC, and HCPCS coding.

• Knowledge of CMS regulations impacting Medicare Advantage, HHS-ACA, and DHS/BadgerCare Plus members in relation to revenue management.

• Proficiency in Word, Excel, and Access.

• Certification as a Professional Coder and/or Certified Risk Adjustment Coder from the American Academy of Professional Coders is required within one year of hire.

🏝️ Benefits

• Full-time schedule.

• Day shift.

• 40 scheduled weekly hours.

• No union position.

• EEO/AA employer M/F/Disability/Vet.

• Disability accommodation assistance for the online application.