Professional Coding Compliance Auditor

Overview:

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Description:

The Professional Coding Compliance Auditor develops and executes audit, monitoring, and education for professional billing, coding and documentation programs that confirm compliance, identifies reimbursement implications, and provides billing providers with relevant and timely information regarding audit results and risk areas.

Principal duties and responsibilities:

• Prepares and oversees professional billing and coding components of the Compliance work plan reflecting scheduled activities and target dates.
• Leads focused audits and reviews to assess adherence with professional billing compliance policies, legal and regulatory requirements, and to identify and evaluate risk areas.
• Assists in development of organizational compliance auditing and monitoring activities for professional billing and coding, including periodic reviews of the individual department auditing and monitoring functions.
• Coordinates sample reviews to ensure codes that were billed are properly supported by appropriate provider documentation.
• Creates audit result reports to be reviewed with providers.
• Organizes and schedules audit findings/education sessions with providers to review audit results.
• Conducts sample and focused reviews to ensure provider coding and billing is compliant with government and payor guidelines.
• Analyzes and reviews medical record documentation and billing data for all pertinent internal and external audits.
• Collaborates with clinical and administrative staff and leadership to ensure audit results are disseminated and understood.
• Manages investigations and audit findings in MDAudit and communicates with the Manager, Compliance Audit and Analysis if audit findings need to be escalated and entered into the Departments issues tracking system.
• Supports professional billing compliance education including auditing, trending, and feedback to providers and professional coders. Manages and fosters relationships with internal professional coders, coding educators and managers and third-party clinical reviewers.
• Assists with development and delivering educational and training programs for professional billing and clinical compliance based on the latest Federal and State regulations to appropriate providers and caregivers.
• Collaborates with other staff who may be conducting focused professional billing compliance audits and/or other special projects included in the annual departmental work plan.
• Maintains required credentials, participates in continuing education opportunities to remain current with billing and coding compliance best practices (i.e., conferences, workshops, and other professional development activities).
• Actively participates in departmental meetings and activities, attends meetings and in-service/educational programs and other activities as requested.
• Maintains confidentiality of patient/members and staff information.
• Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

Education and experience requirements:

• Bachelors degree required.
• Current Professional Coders (CPC) or other relevant and industry-recognized certification required. Certification in Healthcare Compliance preferred.
• Minimum of three (3) years of experience with audit activities required.
• Proficient in MDAudit Enterprise software and Epic electronic health record systems.
• Thorough knowledge of coding documentation improvement practices.
• Thorough knowledge and understanding of billing, coding, and documentation requirements, Federal and State regulations, unbundling edits, medical necessity, clinical best practices, and professional billing requirements.
• Project management experience preferred.

Knowledge, skills, and ability requirements:

• Knowledge of legal, regulatory, and policy compliance issues related to coding, billing, procedures, and documentation.
• Ability to clearly communicate coding information, including the results of coding compliance audit activities.
• Proficiency in root cause analysis, critical thinking, and gaining acceptance of recommended solutions.
• Team player and understands role in relationship to others.
• Strong interpersonal and communication skills.
• Clear, concise, and persuasive writing and presentation skills.
• Strong orientation to deadline and detail.
• Strong organizational and project management skills.
• Working knowledge of computer software Word, Access, Excel, PowerPoint; as well as EMR.
• Knowledge of healthcare financial management principles/practices.
• Ability to work in highly matrixed environments.
• Ability to be flexible and adapt to change.

Additional Details:

Emory Healthcare (EHC) is committed to achieving a diverse workforce through equal opportunity and nondiscrimination policy in all aspects of employment including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training.

PHYSICAL REQUIREMENTS (Medium Max 25lbs): up to 25 lbs., 0-33% of the work day (occasionally); 11-25 lbs., 34-66% of the workday (frequently); 01-10 lbs., 67-100% of the workday (constantly); Lifting 25 lbs. max; Carrying of objects up to 25 lbs.; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.

Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.