Allegheny Health Network Coding Auditor
General Overview: Performs all related internal, concurrent, prospective, and retrospective coding audit activities. Reviews medical records to determine data quality and accuracy of coding, billing, and documentation related to DRGs, APCs, CPTs, and HCPCS Level II code and modifier assignments, ICD diagnosis and procedure coding, DRG/APC structure according to regulatory requirements. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, training, process changes, risk reduction, optimization of reimbursement with new and current coders in accordance with coding principles and guidelines. Promotes cooperation with CDMP and compliance programs to improve documentation which supports compliant coding. Interacts with external consultants regarding billing, coding, and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines.
Essential Responsibilities:
- Plans and conducts audits and reports on the documentation, coding, and billing performed at AHN entities.
- Reviews, develops, and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements.
- Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact, and profitability.
- Validates the ICD-CM, ICD-PCS, CPT, and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements.
- Is responsible for or works with external resources to create and monitor inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends, and variations in the facilities frequently assigned DRG/APC groups.
- Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD-CM ICD-PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines.
- Performs other duties as assigned or required including training/mentoring of new staff, performing audits and research related to special projects and providing coverage for coding manager(s).
- Depending on location provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology, and disease processes as it relates to the DRG/APC and other clinical data quality management factors.
- Other duties as assigned.
Qualifications:
Minimum: High school diploma / GED Certification from American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) AHIMA Credentials (Inpatient or Outpatient): Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) AAPC Credentials (Outpatient): Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA) 5 years with hospital or physician coding and/or auditing, as well as, education techniques and methods. (Internal transfer and promotion candidates may have a minimum of 3 years experience) In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems. Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective Payment System and Coding Clinic references. Current working knowledge of encoder, grouper, abstracting, and other related software. Strong analytical and communication skills Preferred: Associate's Degree 3 years with claims processing and data management Past auditing and strong education/training background in coding and reimbursement
Pay Range Minimum: $25.85 Pay Range Maximum: $40.18