Outpatient Medical Documentation Auditor - Full-time Remote

This is a remote position.

Job Summary:

The Medical Documentation Auditor ensures accurate and complete documentation through compliance and encounter audits and clinician feedback. Provides documentation feedback to clinicians from E&M CPT and ICD9 audits conducted using all state/federal and thirdparty payor regulatory standards for outpatient groups.

Essential Responsibilities:

Core Audit Responsibilities:

• Conduct concurrent and retrospective audits of documentation supporting E/M CPT and ICD9 codes assigned by clinical staff.
  
• Research correct coding practices in relation to applicable rules regulations and coding conventions for billing to determine compliance with Federal State and thirdparty payor regulations.
  
• Review audit findings with individual physicians making suggestions for documentation improvements.
  
• Provide feedback to clinicians based on Federal and State government billing and coding guidelines.
  
• Plan schedule and perform comprehensive chart audits to identify operational and regulatory issues related to coding documentation and compliance requirements.
  
• Ensure complete and accurate data capture in compliance with Federal and State requirements.
  
• Design and implement methodologies to ensure accurate and complete E&M CPT and ICD9 coding audits.
  
• Provide technical expertise to leadership to identify and resolve coding and chart documentation problems impacting the accuracy and consistency of coded data.
  
• Work with Trainers to address operational processes that hinder encounter data capture.
  
• Enter audit results into audit tools to support quality assurance processes analysis and training activities.
  
• Review analytical data and audit findings to identify coding trends and other risk areas and recommend appropriate actions.
  
• Conduct quality assurance reviews and collaborate in the development and execution of audit and training plans.
  
• Assist in developing and implementing policies and procedures to ensure compliance with Federal State and other regulatory requirements.
  

Requirements

Qualifications:

• Minimum three (3) years CPT ICD9 and E&M Coding experience.
  
• Bachelors degree in business administration health care public health finance business medical records technology or four (4) years of experience in a related field.
  
• High School Diploma or General Education Development (GED) required.
  
• Certification as a Certified Coding Specialist Certified Professional Coder Hospital Outpatient Registered Health Information Administrator Registered Health Information Technician or Certified Professional Coder.
  
• Proficient in the use of PC applications such as MS Word Excel Access and PowerPoint.
  
• Experience conducting Medical Record audits and interpreting and applying Federal and State regulations coding and billing requirements.
  
• Comprehensive knowledge of medical diagnostic and procedural terminology.
  
• Ability to provide constructive and sensitive feedback to providers and leadership regarding federal and state coding medical documentation and compliance guidelines.
  
• Ability to work with and maintain confidentiality of physician patient patient account and personnel data.
  
• Knowledge of outpatient coding practices.
  
• Strong interpersonal written verbal and presentation skills.
  
• Ability to work independently with minimal supervision prioritize workload and meet deadlines.
  
• Ability to read and interpret medical data.
  
• Willingness to be flexible depending upon department and/or physician schedule needs.
  
• Experience using electronic health record systems and webbased applications preferred.