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 third-party 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 third-party 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.
• Bachelor's 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 web-based applications preferred.