Medical Practice Code Auditor

POSITION SUMMARY:

The role of the Medical Practices Coding and Compliance Auditor is to increase and strengthen physician awareness and understanding of medical record documentation and coding guidelines. This is accomplished through ongoing chart review and the development of educational programs. In addition, the medical practices coding and compliance auditor will collaborate with appropriate parties to ensure that compliance guidelines are met for the SGMG organization.

MINIMUM QUALIFICATIONS :

EDUCATION:

High School diploma or equivalent required.

REQUIRED LENGTH AND TYPE OF EXPERIENCE:

Three years experience working in a medical claims environment

LICENSURE, CERTIFICATION OR REGISTRY:

CPC or CCS-P credentials required. Must obtain the required CEU credits necessary to maintain Coding Certification Credentials.

PRINCIPAL DUTIES AND RESPONSIBILITIES: Essential Functions of the Position

1. Responsible for the coordination of any audit activities including internal, external and third party payer audits including Federal & State agencies.

Annual Compliance Audits

CBO Billing Audits

Medicare Audits

2. Ensures that annual compliance audits are completed as scheduled, compares documentation to billing for discrepancies or missed charge opportunities, prepares a written plan of action and standard reporting for management review.

3. Responsible for the investigation and suggested resolution of compliance issues related to the coding of physician charts, billing and reimbursement for services.

Monthly Audits based on the OIG areas of risk

4. Provides data compilation and analysis of coding, billing and reimbursement issues to the physicians, the SGMG Director and other SGMG administrative staff.

5. Responsible for identification of coding deficiencies and the participation of educational programs for new and established physicians and staff on coding, documentation and reimbursement.

E/M Coding

Compliance Risks

Maximizing Reimbursement

Communication of government and private payer updates

Implement a Coding Newsletter to distribute to practices monthly

Provides orientation of new physicians and staff in the use of charge tickets, hospital cards and coding guidelines.

6. Collaborate with responsible parties for the periodic review of billing policy compliance.

Charge Reconciliation Process

7. Responsible for researching coding questions and making final decisions based on extensive research of publications and manuals.

8. Plans and organizes work activities to ensure targeted results are met based on SGMG's annual work plan.

9. Ensures compliance with all federal, state, and local regulations governing coding, documentation and reimbursement guidelines.

10. Maintains working knowledge of all managed care contractual relationships and ensures that documentation and coding requirements contained within are followed.

11. Participates in the annual charge ticket maintenance in regards to accurate CPT & ICD-9 codes (ICD-10)

12. Participates in the education of the new ICD-10 regulations

13. Maintains strict confidentiality in regard to patient's personal, medical and financial information.

14. Acts as a role model for professionalism through appropriate conduct and demeanor at all times.

15. Performs additional duties as assigned.

Required Skills

1. Excellent interpersonal skills to work in partnership with others to influence and gain cooperation.

2. Ability to recognize, evaluates, and solves problems.

3. Strong verbal and written communication skills.

4. High tolerance level for dealing in a potentially stressful environment.

5. High knowledge of the claims development process, as well as third party insurance program requirements.

6. Must possess a high knowledge of ICD-9 (transition to new ICD-10) and CPT coding as well as reimbursement.

7. Computer literate, experience with basic software packages.

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Southwest General Health Center with an excellent service experience by consistently demonstrating our Standards of Performance each and every day.