Coding and Medical Records Auditor

🔥 0 minutes ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 10%

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American Health Partners

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1976

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

American Health Partners is a healthcare organization focused on improving access to and coordination of high-quality care through a continuum of services tailored to institutional and special-needs populations. The company operates institutional special needs health plans and provides specialized care coordination, geriatric inpatient and acute psychiatric care, and pharmacy services for long-term-care facilities, supported by an owned/affiliated network of locations and thousands of contracted providers. American Health Partners emphasizes convenient, preventive care to reduce costly hospital stays and improve patient outcomes and quality of life.

📋 Description

• Conduct coding audits prior to claims submission • Ensure appropriate and accurate coding is applied for each plan member • Perform post-payment coding reviews and send coding education correspondence to providers • Review claims prior to billing to improve accuracy • Assess coding trends and communicate education to staff and the organization • Review medical records and clinical documentation to verify accuracy, completeness, specificity, and appropriateness of diagnosis codes • Conduct pre-claim and post-claim coding audits • Work with the delegated claim processor to review and correct errors before final payment • Assist with validation audits of medical record documentation and ICD-10 coding submitted to CMS • Interpret medical documentation to capture relevant CMS Hierarchical Condition Categories (HCC) conditions for Medicare Risk Adjustment reimbursement • Complete assigned coding projects • Provide customer service to internal and external customers while meeting quality and productivity expectations • Escalate coding audit issues to management and follow policies and procedures • Maintain production and quality standards • Work with provider representatives and executive directors on Letters of Agreement (LOAs) • Ensure regulatory compliance and quality by applying coding standards • Follow applicable Federal and State regulatory requirements and company procedures • Participate in ad-hoc coding audits and perform other assigned duties

🎯 Requirements

• 3 years HCC coding and/or coding and billing required • 5 years HCC coding and/or coding and billing preferred • 2+ years of complex claims processing and/or coding auditing experience in the health insurance industry or medical health care delivery system recommended • 2+ years of experience in managed healthcare environment related to claims and/or coding audits recommended • Knowledge of standard coding and reference materials used in a claim setting, such as CPT4, ICD10, HCPCS and others • Knowledge of CMS requirements regarding claims processing and coding, especially Skilled Nursing Facility and other complex claim processing rules and regulations • Experience coding/auditing claims for Medicare and Medicaid plans • Required certification: any of Certified Professional Coder (CPC), Certified Risk Coder (CRC), Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), or Registered Health Information Technician (RHIT)