JOB SUMMARY:
TruHealth is the clinical arm of the health plan and supplies the model of care. The Coding and Medical Records Auditor will be
responsible for conducting coding audits prior to claims submission. This position will ensure appropriate and accurate coding is
applied for each member of the plan. Additionally, post-payment coding reviews may be performed with coding education
correspondence sent to providers
The Coding and Medical Records Auditor will be responsible for conducting coding audits prior to claims submission. This position will ensure appropriate and accurate coding is applied for each member of the plan. Additionally, post-payment coding reviews may be performed with coding education correspondence sent to providers.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
- Review claims prior to billing to provide a proactive level of accuracy.
- Assess trends; communicate appropriate education both individually to staff and collectively as an organization.
- Review medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries as needed to verify and ensure the accuracy, completeness, specificity, and appropriateness of diagnosis codes based on services rendered.
- Conduct pre-claim and post-claim coding audits to ensure accurate claims' denials.
- Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment.
- Assist with validation audits to evaluate medical record documentation to ensure coding accurately reflects and supports relevant coding based on the ICD-10 code submitted to CMS and interpretation of medical documentation to ensure capture of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions applicable to Medicare Risk Adjustment reimbursement initiatives.
- Work assigned coding projects to completion.
- Provide a high level of customer service to internal and external customers by consistently meeting and/or exceeding expectations including but not limited to quality and productivity.
- Escalate appropriate coding audit issues to management as required and follow departmental/organizational policies and procedures.
- Maintain required levels of production and quality standards as established by management.
- Work directly with provider representatives and executive directors on Letters of Agreement (LOAs) to ensure appropriate coding methodology and reimbursement.
- Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of coding standards.
- Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations or as documented in company policies and procedures.
- Participate in and support ad-hoc coding audits as needed.
- Other duties as assigned
EXPERIENCE:
- 3 years HCC coding and/or coding and billing required
- 5 years HCC coding and/or coding and billing preferred
- 2+ years of complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system recommended.
- 2 + years of experience in managed healthcare environment related to claims' and/or coding audits recommended.
- 2 year(s): Knowledge of standard coding and reference materials used in a claim setting, such as CPT4, ICD10, HCPCS and others
- 2 year(s): Knowledge of CMS requirements regarding claims processing and coding; especially Skilled Nursing Facility and other complex claim processing rules and regulations
- 2 year(s): Coding/auditing claims for Medicare and Medicaid plans.
- 2 year(s): Experience in managed healthcare environment related to coding audits
- 2 year(s): Complex claims processing and/or coding experience in the health insurance industry or medical health care delivery system
LICENSE/CERTIFICATION: REQUIRED (any of the following):
- Certified Professional Coder (CPC)
- Certified Risk Coder (CRC) · Certified Coding Specialist (CCS)
- Certified Documentation Integrity Practitioner (CDIP)
- Certified Clinical Documentation Specialist ( CCDS)
- Registered Health Information Technician (RHIT)