Medical Coding Auditing Specialist

Job Description

Description

The work of the Medical Coding Auditing Specialists involves, but is not limited to:

Verify the accuracy of the diagnosis, procedure, supply codes, modifiers, and sequencing for the professional and institutional (facility) components of Inpatient, External Resource Sharing Agreement (ERSA), Ambulatory Procedure Visit (APV), Observation, Emergency Department (ED), and Outpatient encounters. Codes audited include International Classification of Diseases, Clinical Modification (ICD-CM), International Classification of Diseases, Procedural Classification System (PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and modifiers. Assign errors IAW DHA-MCPB policies, procedures, rules, and standards, and provides clear, concise, official coding guidance, rationale, and reasons for assigning specific errors. Ensure strict confidentiality of medical records and audit findings.

Provide second-level review of coding assignment to ensure compliance with legal and procedural policies to ensure optimal reimbursements while adhering to regulation prohibiting unbundling and other questionable practices. Review encounter and/or record documentation to identify inconsistencies or discrepancies that may cause inaccurate coding, medico- legal repercussions or impacts quality patient care. Identify any problems with legibility, abbreviations, etc., and brings to the provider’s attention. Examine records for proper sequence of documents, presence of authorized signatures, and sufficient data is documented that supports diagnosis, treatment administered, and results obtained. 

Assist in developing an annual work plan of analysis, audit, and investigative items in collaboration with DHA/PAD. Stay abreast of changes in Federal laws, Department of Health and Human Services Office of Inspector General (HHS- OIG), DoD, DHA, and AFMS regulations, and commercial policies involving or affecting compliance. Collaborate with DHA leadership and clinical staffs in identifying and resolving compliance issues. 

Qualifications

 Advanced knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM), and Procedural Coding System (PCS); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).

Advanced knowledge of reimbursement systems, including Prospective Payment System (PPS) and Diagnostic Related Groupings (DRGs); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS).

Advanced knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.

Practical knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology); and revenue cycle management concepts.

Thorough understanding of Government rules and regulations regarding medical coding, reimbursement guidelines, and healthcare fraud; commercial reimbursement guidelines and policies; coding audit principles and concepts, and potential areas of risk for fraud and abuse. Includes, but is not limited to:  The Federal Register, Center for Medicare, and Medicaid Services (CMS) Local Coverage Determinations and National Coverage Determinations (LCD and NCD), National Correct Coding Initiative (NCCI) guidance, manual, and edits, Internet-Only Manuals (IOMs), and HHS-OIG publications and reports.

 Practical knowledge of revenue cycle management, project management concepts, business analysis, training methods, clinical documentation improvement, and continuous process improvement processes.

Practical knowledge of Current Dental Terminology (CDT).

A minimum of eight (8) years of medical coding and/or auditing experience in four (4) or more medical, surgical, and ancillary specialties within the past 15 years. A minimum of one (1) year of performance in the specialty is required to be qualifying. Multiple specialties encompass different medical specialties (i.e., Family Practice, Pediatrics,  Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes. Ancillary specialties (PT/OT, Radiology, Lab, Nutrition, etc.) that usually do NOT use E&M codes do not count as qualifying experience. Coding experience should include inpatient facility and mbulatory surgery areas. Additionally, coding, auditing, and training exclusively for specialties such as home health, skilled nursing facilities, and rehabilitation care will not be considered as qualifying experience. Coding experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable) is not a qualifying factor.

Four (4) years of the eight (8) years of required coding experience must involve medical coding auditing functions. Auditing functions include development and execution of audit plan, conducting audit according to audit plan by reviewing required documentation and determining compliance with audit standards, communicating with stakeholders during all phases of audit, and reporting on audit findings.

Required Coding Certifications:

Medical Coding Auditing Specialists are required to possess a coding certification in good standing in each of the following categories:

1. RHIT/RHIA/CPC/CCS-P

2. RHIT/RHIA/CIC/CCS

3. CEMA

4. CPMA

* The AHIMA RHIT or RHIA credential may be counted toward 1. Or 2.  but not both unless the individual possesses the required institutional AND professional services experience for the specific position sought.

 Continuing Education Requirements:   Medical coding personnel shall maintain the required continuing education hours in order to maintain current and proper national certification(s) requirements for this position.

Overview

SAIC is a premier technology integrator solving our nation's modernization and readiness challenges. Our offerings across defense, space, civilian, and intelligence markets include high-end solutions in engineering, IT, and mission outcomes. We integrate the best components from our portfolio with our partner's ecosystem to deliver innovative and effective solutions. We are 25,500 strong; driven by mission, united by purpose, and inspired by opportunities. Headquartered in Reston, VA, SAIC has annual revenues of nearly $7.1 billion. SAIC is an Equal Opportunity Employer empowering people no matter their race, color, religion, sex, gender identity, sexual orientation, national origin, disability, or veteran status.  We strive to create a diverse, inclusive and respectful work culture that values all.