Job Summary:
Works independently performing program, compliance and risk-based reviews of health care related activities to ensure accuracy of related medical record documentation, coding, billing and policies. Provides written audit summary of findings to include audit recommendations. Conducts revenue cycle investigations to determine and mitigate risk through findings, reports, and recommended actions through an action plan. Responsible for coordinating, developing and conducting educational training based on audit outcomes. Provides educational training to coders, billers, physicians, and others on documentation requirements and correct coding of inpatient, outpatient and professional fee services. Assists Corporate Compliance in maintaining the hospital's Corporate Compliance Program.
Job Requirements:
Education and Work Experience:
- Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Five years' experience in healthcare coding inpatient, outpatient, rural health care and/or professional fee services: Required
- Three years' experience in auditing in clinic and/or facility revenue cycle: Preferred
Licenses/Certifications:
- Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist - Physician (CCS-Phy): Required
- Certified Professional Medical Auditor (CPMA) or Certified E&M Auditor (CEMA) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified in Healthcare Compliance (CPC) or Certified E/M Coder (CEMC) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist - (CCDS): Preferred
- CCS OR CCS-Phy OR CPC: Required
Essential Functions:
- Performs comprehensive reviews of health care records for accuracy of revenue cycle billing compliance to include but not limited to: medical necessity, compliance risk, review of denials, charge trends, and applied CPT, HCPCS, ICD 10-CM and ICD-10-PCS coding guidelines for inpatient, outpatient, and/or clinic visit encounters that correlates to clinical documentation.
- Produces comprehensive audit finding reports that include quantifiable impact, identify areas of opportunity for education, as well as improvement recommendations. Generates audits utilizing Auditing platform for denials, coding reviews and other risk-based data for department audits as appropriate.
- Communicates clearly (verbally and in written reports or summaries) opportunities regarding proper clinical documentation guidelines, service selection, charge capture and timely submission, healthcare data accuracy and coding principles.
- Participates in improving the efficient and effective delivery of the Department's services including promoting the department brand, complying with department and professional standards, participating in department initiatives and internal process improvement projects, and providing input into the enhancement of audit methodologies, workflows and tools. Participates in annual risk assessment and work plan development processes.
- Works collaboratively in a team environment to support the hospital, surgical and clinical practices as well as AH leadership on revenue cycle compliance.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
