Coding Audit Specialist, Health Plan

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland.

Work Shift:

Day (United States of America)

Scheduled Weekly Hours:

40

Compensation:

Salary Range: $21.50 - $34.50

Union Position:

No

Department Details

Summary

The Coding Audit Specialist position conducts quality assurance activities to ensure the accuracy and integrity of risk adjustment data submitted to the Centers for Medicare & Medicaid Services (CMS) and Department of Health Services (DHS); identifies deficiencies and provides management with an analysis of outcomes and tools for improving accuracy in coding. Responsible for auditing medical record documentation to determine appropriate diagnostic coding for services provided, taking into account the AMA CPT coding guidelines, ICD‐9 & ICD‐10 Coding Guidelines, CMS Medicare, HHS, and DHS BadgerCare Plus risk adjustment policy and Hierarchical Condition Category Coding.

Job Description

Develops, implements and monitors, along with risk adjustment leadership, to provide a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange and Medicaid/BadgerCare Plus member diagnosis documentation. Audits medical record documentation to ensure correct codes have been selected and to detect un‐coded or miscoded diagnoses for the Medicare Advantage, ACA/Exchange and BadgerCare Plus member populations. Develops and maintains the skills necessary to accurately audit the coding for visits (evaluation and management) and procedures documented by physicians, hospitals and other providers in the various specialties and subspecialties as it relates to HCC coding. Maintains knowledge of CPT coding rules, ICD‐9 and ICD‐10 codes, HCPCS codes, HCC coding, use of modifiers, documentation guidelines, CMS Policy requirements, and other reimbursement guidelines to ensure accurate documentation review and diagnosis code assignment. Reviews components of the provider's documentation and compares the documentation with the requirements of the code(s) reported to verify that documentation supports the code(s) reported. Formulates an outcome for each audit, identify correct or incorrect coding to ensure audit findings are presented in a logical, concise summary.

Qualifications

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. Associate Degree in coding and/or health‐related field preferred.

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 the different CMS guidelines that affect 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.

Sanford is an EEO/AA Employer M/F/Disability/Vet.

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