Summary:

A senior level compliance coding auditor conducting assessments in accordance with The Guthrie Clinic’s policies and procedures and accepted guidelines for medical coding. 
Works closely with the Compliance Officer and Compliance coding Audit Coordinator to perform audits outlined in the work plan. Requires ability to present detailed analysis of audits in both written and spoken form.
Relies on professional judgement to ensure Internal Audit and Compliance standards are used to assess compliance with CPT, ICD-9/10, HCPCS, Payor, CMS guidelines and TGC policies

Experience:

Working knowledge of medical terminology, anatomy and physiology, and coding guidelines including CPT, ICD- 9 /10-CM, and HCPCS coding systems and guidelines, payer guidelines and requirements. Minimum 1-year experience in Physician coding and billing and/or compliance field required 5 year of clinical experience and/or knowledge and understanding of Medical Records auditing process preferred. Required to sit for CPC exam within one year.

Education:

Associates degree required; Bachelor’s preferred

Licenses/Certifications:

AHIMA (RHIA, RHIT, or CCS) or AAPC (CPC) required RN/LPN or CPMA preferred Required to sit for CPC exam within one year   

Essential Functions:

Conducts auditing for accuracy of coding, leveling, and provider documentation in compliance with accepted guidelines (federal, state, local, and insurance regulations as well as The Guthrie Clinic policies, as applicable, Medicare, Medicaid, and LCD (Local Coverage Determinations), and NCD (National Coverage Determinations), insurance companies) Performs, and reports coding audits based on the Internal Audit and Compliance Work Plan including completing other special auditing projects as requested, communicating audit findings by preparing final reports and discussing findings with providers and/or staff, as appropriate, and maintaining excellent documentation of all reviews, methodologies employed, results, corrective actions implemented, and monitoring Complete and submit external audits that come from state and federal agencies including coordinating with the appropriate departments to gather required documentation requested from the agencies and ensure timely submissions, as well as communicating external audit findings with senior leadership, providers and/or staff, as appropriate Assists in educating and training providers and staff in relation to coding, billing and compliance issues Assists in developing annual work plan based on identified external and internal risks.  Audits include OIG, OMIG – New York, LCD (Local Coverage Determinations), and NCD (National Coverage Determinations), performing Internal risk assessments, and reviews past audit insufficiencies or reports of non-compliance Maintains professional and technical job knowledge by participating in educational opportunities, reading professional publications, establishing, and maintaining personal networks, and participating in professional organizations Enhances compliance department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments Work closely with internal billing and reimbursement departments to ensure internal processes are understood Maintains knowledge and proficiency in the Epic EMR, PARC, HIM/ROI, and Microsoft Office as needed Communicates the results of compliance reviews/audits with all parties involved to ensure understanding of outcomes and any need for corrective actions. Research risk areas and compliance concerns related to coding and payer requirements and provides analysis to Compliance Officers or management as required. Research legislation, standards, and policies related to HIPAA privacy and security regulations and provides analysis to Compliance Officers or management as required Maintains excellent documentation of all reviews, methodologies employed, results, corrective actions implemented, and monitoring through departmental workplan

Other Duties:

Travel for this position is sometimes required.  Participation in community and employee engagement activities is required.   It is understood that this description is not intended to be all-inclusive and that other duties may be assigned as necessary in the performance of this position.

Rev: 7-2-2024