Auditor - Outpatient Coding

Job Description

Role & responsibilities Conducts acute outpatient coding reviews to validate diagnosis, CPT, HCPCS and modifiers. Analyzes all other coded data for completeness, accuracy, compliance and adherence to coding guidelines. Writes clear, accurate and concise recommendations in support of findings while providing feedback and education to coders referencing current ICD-10-CM, CPT Official Coding Guidelines and AHA Coding Clinics Responsible for knowledge, understanding and application of National Correct Coding Initiative (NCCIs) edits, including but not limited to Procedure-to-Procedure edits (PTPs) edits; Medical Unlikely Edits (MUEs); Add-On Codes (AOC’s) to ensure accurate reimbursement and compliance with Medicare guidelines. Extensive understanding of OCE billing edits as it relates to outpatient facility coding. Industry knowledge of Medicare regulations and payment policies, including OPPS and how they apply to acute outpatient coding and billing. Maintains productivity and quality goals as set by audit leaders. Audit evaluation and management codes for the Emergency Department including thorough knowledge of American College of Emergency Physician (ACEP) Facility guidelines or similar. Ensures client coding audits are completed accurately and timely by meeting client turn around and audit quality expectations. Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines. Demonstrates a broad understanding of charge capture, revenue integrity and charge master (CDM) concepts to help prevent noncompliance risks, optimize payments and minimize downstream issues with claim edits. Completes required internal education, compliance training and other mandatory educational requirements. Utilize proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately. Ensure the confidentiality and rights of the patient and the client health system. And must maintain all required client access. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. Preferred candidate profile 3+ years of overall experience with 1+ years of experience in Quality Analysis within the healthcare / RCM domain. Strong understanding of end-to-end RCM processes including charge entry, payment posting, denial management, and AR follow-up. Knowledge of HIPAA and healthcare compliance standards. Proficiency in using billing software (e.g., Epic, Athena, Kareo) and QA tools. Excellent communication skills for feedback and reporting.