Coding Compliance Auditor

DEPARTMENT: Revenue Management

WORK SCHEDULE: Days

WORK TYPE: Full Time

JOB SUMMARY

Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations.  The auditing process reviews and analyzes this function as performed by physicians, advanced practitioners and coders.  Those responsible for coding translate diagnostic and procedural phrases into coded form such as ICD-10-CM, HCPC Level II, and CPT codes that are utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The auditor’s function is to assess that this is done accurately and compliantly.  These functions, performed by those holding specialized credentials, utilize various resources to ensure compliance with national and local coding guidelines. 

MAJOR DUTIES AND RESPONSIBILTIES

 Reviews the content of the medical record to identify diagnoses and procedures performed, level of service obtained, and complicity with standard coding regulations.  Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, consultations, orders, and various other notes/treatment records. 

Translates diagnostic and procedural phrases utilized by healthcare providers into coded form using ICD-10-CM, HCPC, and CPT codes.  Maintains expert knowledge of these principles.

Reviews systems established to ensure compliance with policies, plans, procedures, Federal and state laws and regulations, protocols and third-party requirements which have significant impact on operations and reports in determining revenue compliance.  As such, conducts research into complex coding issues upon request of leadership and other departments (i.e. Coding, Revenue Management Practice Consultants, Professional and Hospital Billing) to render guidance and offer an informed, objective opinion.

Remain abreast of relevant Local Coverage Determinations, National Coverage Determinations, billing and coding guidelines.

Assists in determining audit plan and program of examination for the assigned areas being audited and maintains proficiency in all service lines and specific nuances of such.

Analyzes the results of service line audits and identifies any error trends which require either process changes or additional training. Prepares or assists in preparing formal written summaries and follow up memorandums expressing opinions on the adequacy and effectiveness of the assigned areas being audited.    Presents the results of audits to physician, operational, and coding leadership to include discussion of coding and documentation issues and the identification of corrective actions.

Evaluates the adequacy of corrective action and education designed to address the findings noted in an audit by performing assigned follow-up review activities.

Reviews findings from third-party payer audits and assesses the accuracy of the finding and makes recommendations on the response to the payer and needed changes to internal processes. Makes recommendations in regard to further appeal.

Through the course of audit and review activities, identifies potential larger compliance issues and conducts appropriate research to provide an informed opinion to management.

Maintains and improves coding skills by participating in continuing education sessions as appropriate; maintain certified coding credential.

Achieves department specific performance parameters for audit confidence.

Completes administrative duties necessary to the normal operations of the Revenue Management Compliance upon request.

 Performs other duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform.

 SPECIFIC POSITION DUTIES

Accountable for satisfying all job specific obligations and complying with all organization policies and procedures.

COMPENTENCIES AND SKILLS

Knowledge of and ability to use office support tools available at the desktop (e.g., word processing, e-mail, presentation software and spreadsheets).

Demonstrates strong and elevated organizational skills and able to plan prioritize complex work duties.

Must be able to work and communicate effectively in a team environment.

Demonstrates the ability to prioritize and manage a variety of tasks and/or projects in a fast-paced environment.

Knowledge of and ability to manage the major responsibilities, accountabilities, and organization of the Audit and Compliance (A&C) function or department.

EDUCATION AND/OR EXPERIENCE

Required Experience:

Minimum of 6 years in related work experience

Preferred Experience:

Required Education:

Associate's degree Healthcare Related Degree or equivalent experience in lieu of degree

Preferred Education:

Bachelor's Degree in Related Field of Study

Required Certifications or Licensures:

CERT_CERTIFIED PROFESSIONAL CODER (CPC)

OR

208CERT_CODING SPECIALIST

OR

CERT_REGISTERED HEALTH INFORMATION TECHNICIAN (RHIT)

OR

460C 

ERT_REGISTERED HEALTH INFORMATION ADMINISTRATOR (RHIA)

WORKING CONDITIONS/PHYSCIAL DEMANDS

Work is typically performed in an office environment

OUR PURPOSE & VALUES:Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.

ABOUT GEISINGER: Geisinger is a physician-led health system comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, and a 583,000-member health plan Geisinger is nationally recognized for innovative practices and quality care. Geisinger serves more than 3 million people in central, south-central and northeast Pennsylvania and also in southern New Jersey with the addition of National Malcolm Baldridge Award recipient AtlantiCare, A member of Geisinger. In 2017, the Geisinger Commonwealth School of Medicine became the newest member of the Geisinger Family.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. For more information, visit www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter.

** Does not qualify for J-1 waiver.  We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply.  All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

*Domestic partner benefits not applicable at Geisinger Holy Spirit.