Position Class Code/Title: B4003 / Medical Coding Auditor
FOR BEST CONSIDERATION DATE: OPEN UNTIL FILLED
UNM Medical Group, Inc. (UNMMG) is the practice plan organization for physicians and other medical providers associated with the UNM Health Sciences Center. UNM Medical Group, Inc. is a New Mexico non-profit corporation and is an equal opportunity employer. UNMMG offers a competitive salary and an attractive benefit package which includes medical, dental, vision, and life insurance as well as tuition assistance, paid leave and 403b retirement for benefits eligible employees.
The UNMMG Compliance department is seeking an enthusiastic Compliance Medical Coding Auditor to join our dynamic team.
The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.
The position of Medical Coding Auditor is extremely important in the daily operations of the Compliance office. Under indirect supervision, will audit medical charts and records for compliance with federal coding regulations and guidelines. Auditor will audit medical record documentation to identify under coded and/or over coded services, prepares reports & observations & meets with providers, support staff to provide education & training on accurate documentation and coding practices in compliance with regulatory requirements. Certification in at least one of the following: CPC, CCS, RHIA or RHIT. Certification or certificate eligible for Certified Professional Medical Auditor (CPMA).
DUTIES AND RESPONSIBILITIES
- Audits medical record documentation to identify under coded and over coded services, prepares reports and observations and meets with providers, support staff and coding personnel to provide education and training on accurate documentation and coding practices in compliance with regulatory requirements. Provides follow up audits when necessary.
- Reviews billing processes to ensure accurate reimbursement and compliance with regulatory and procedural policies including unbundling and other questionable practices.
- Researches, analyzes and responds to internal and external inquiries regarding compliance, inappropriate coding, denials and billable services.
- Interacts with physicians, other patient care providers, support staff and coding personnel regarding billing and documentation policies, procedures and regulations; obtains clarification on conflicting, ambiguous or non-specific documentation.
- Trains, instructs and/or provides medical providers, support staff and coding personnel as appropriate regarding documentation, regulatory provisions and third party payer requirements.
- Reviews, develops, modifies, and/or adapts relevant client procedures, protocols and data management systems to ensure that client billing requirements are met for professional and facility services.
- Assists management in the formulation of the annual work plan and formulates audit protocol to capture risks in audit schedule.
- Assists management in the review of external payer requests including but not limited to third party payers, Medicare Advantage plans, and Recovery Audit Contractor reviews for reconsideration, appeal and rebuttal actions.
- Collaborates with hospital compliance and coding staff to ensure that provider education and training for professional and facility services is accurate and consistent.
- Ensures strict confidentiality of medical and financial records.
- Attends coding conferences, workshops and in-house sessions to receive updated coding and auditing information and changes to regulations.
- Performs miscellaneous job related duties as assigned.
MINIMUM JOB REQUIREMENTS
High School diploma or GED with 5-7 years of directly related experience to the duties and responsibilities specified plus certification in at least one of the following CPC, CCs, CCS-P, COC, RHIA or RHIT, CHONC. Certification or certificate eligible for Certified Professional Medical Auditor (CPMA). Verification of education and licensure will be required if selected for hire.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED
- Advanced knowledge of auditing concepts and principles with increased awareness of regulatory, compliance and focused payer specific audits (prospective and retrospective)
- Advanced knowledge of “how to prepare for an investigation” to ensure strict confidentiality of financial records and personal/professional matters related to medical providers
- Ability to use independent judgment and to manage and impart confidential information in all compliance related issues
- Advanced comprehensive knowledge of medical anatomy, terminology, ICD 9 & ICD 10 and CPT/HCPCS medical coding
- Ability to analyze, research and solve problems
- Advanced knowledge of legal, regulatory and policy compliance issues related to medical coding and billing procedures as well as documentation requirements (i.e. federal, state, and third party payer regulations)
- Comprehensive knowledge of current and developing issues and trends in compliance, medical coding and auditing procedures
- Excellent oral/writing skills to clearly communicate with medical providers, clinical management and clinical technical coding staff to provide education and training on accurate coding and reimbursement practices and compliance issues.
- Ability to develop and deliver effective training materials to faculty and staff within the area of professional specialty
- Skilled in the use of computers preferably PC-based operating environment working with Microsoft Office products such as Excel, Word, Power Point and Access as well as Cerner. IDX/Claims Manager, electronic editing and coding auditing systems
- Knowledge and understanding of how to prepare rebuttals and appeal claims, pull EOBs, respond to payers and prepare reports to management
- Knowledge of organizational structure, workflow and operating procedures with a high volume medical billing practice environment
- Advanced knowledge of medical documentation, fraud, waste and abuse penalties for documentation violations based on governmental guidelines, coding concepts, scope and statistical sampling methodologies, medical record auditing skills and abstraction ability
- Performs quality assurance, coding risks analyses and communicates results and observations
- Knowledge of hospital outpatient coding and reimbursement guidelines.
CONDITIONS OF EMPLOYMENT
- Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).
- Must pass a pre-employment criminal background check.
- Fingerprinting, and subsequent clearance, is required.
- Must provide proof of varicella & MMR immunity or obtain vaccinations within 90 days of employment.
- Must obtain annual influenza vaccination.
- If this position is assigned to a clinical area, successful candidate will be required to complete a pre-placement medical evaluation/health screen. Required N-95 mask fitting, testing, vaccinations to include annual TST, Tdap, and Hepatitis B will be determined based on location and nature of position.
WORKING CONDITIONS AND PHYSICAL EFFORT
- Work is normally performed in a typical interior/office work environment
- No or very limited exposure to physical risk
- No or very limited physical effort required