Coding Audit Specialist, Health Plan

🔥 0 minutes ago

🗿 South Dakota, Wisconsin – Remote

🗿 South Dakota – Remote 🧀 Wisconsin – Remote

💵 $21 - $34 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Sanford Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1894

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Sanford Health is the largest rural health system in the United States, dedicated to transforming the healthcare experience and providing access to world-class healthcare in America's heartland. Headquartered in Sioux Falls, South Dakota, Sanford Health serves over 1. 4 million patients and nearly 200,000 health plan members across 250,000 square miles. The integrated health system includes 48 medical centers, 211 clinic locations, and more than 160 senior living centers, employing 2,900 physicians and advanced practice providers. Sanford Health is committed to offering compassionate care through its Centers of Excellence, focusing on specialties such as cancer, orthopedics, women’s health, and genetics. Additionally, it provides affordable health insurance, engages in extensive clinical trials, and supports personalized genetic medicine.

📋 Description

• Conduct quality assurance activities to ensure the accuracy and integrity of risk adjustment data submitted to CMS and DHS • Identify deficiencies and provide management with analysis of outcomes and tools for improving coding accuracy • Develop, implement, and monitor a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange, and Medicaid/BadgerCare Plus member diagnosis documentation • Audit medical record documentation to identify uncoded or miscoded diagnoses • Audit coding for visits and procedures documented by physicians, hospitals, and other providers across specialties and subspecialties as related to HCC coding • Maintain knowledge of CPT, ICD-9, ICD-10, HCPCS, HCC coding, modifiers, documentation guidelines, CMS policy requirements, and reimbursement guidelines • Compare provider documentation with reported code requirements to verify coding support • Formulate audit outcomes and present findings in logical, concise summaries

🎯 Requirements

• High school diploma or equivalent required • Demonstrated knowledge of anatomy/physiology and medical terminology • Completion of courses in Current Procedural Terminology and ICD‐9 and ICD‐10 coding required • Three years of experience required in a health insurance, compliance, quality assurance, or auditing related position • Experience with ICD‐9, ICD‐10, CPT, HCC and HCPCS coding • Knowledge of CMS guidelines affecting Medicare Advantage, HHS‐ACA and DHS/BadgerCare Plus members as related to revenue management • Demonstrated knowledge of Word, Excel, and Access • Certified Professional Coder and/or Certified Risk Adjustment Coder certification awarded by American Academy of Professional Coders required within one year of hire • Associate Degree in coding and/or health-related field preferred