Medical Coding Auditor

Position Summary:

The Medical Coding Auditor conducts audits to provide investigative support related to potential fraud, waste, abuse and/or overpayment. Through pre and post payment medical records review and appeal records review, the Medical Coding Auditor ensures appropriate coding on claims paid and maintains compliance documentation of any fraud, waste or abuse identified based on coding guidelines, coverage policies and regulatory and contract requirements.

Qualifications:

• Medical Coder certification from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) required.
• Prior experience in Medicaid claims role and/or post payment medical coding auditor role preferred.
• Knowledge of Medicaid rules, claims processing, medical terminology and coding principles and practices.
• Knowledge of auditing, investigation, and research.
• Knowledge of word processing software, spreadsheet software, and internet software.
• Manage time efficiently and follow through on duties to completion

Essential Duties and Responsibilities:

1. Maintains a caseload of audit reviews and a caseload of appeals reviews, ensuring movement and timely action taken. Documents time spent through software used.
2. Performs pre and post payment medical record review audits of claims payments to identify potential fraud, waste, abuse and/or overpayment based on contract/regulatory requirements, coding guidelines, and coverage policies.
3. Performs reviews of appeal records received based on contract/regulatory requirements, coding guidelines, and coverage policies, prepares review summary for presentation to the appeals committee, and presents appeal review to the appeals committee. Generates appeal committee determination notice, sends to provider, and tracks for response.
4. Generates statistically valid random samples through software used. Generates audit notice with sample/attestation, sends to provider, and tracks for provider response.
5. Monitors the CCP fax and CCP.SIU inboxes for receipt of medical records.
6. Completes and maintains detailed documentation of audits including but not limited to coding guidelines reviewed, coverage policy documentation, decision methodology, and monetary discrepancies identified.
7. Notifies the provider of audit findings, including but not limited to overpayment, education, and no issues identified.
8. Responsible for reviewing audit and appeal records for potential fraud, waste or abuse, documenting any FWA findings for presentation to Manager, Compliance for further investigation.
9. Documents all audit steps in the case in the software used.
10. Prepares written reports or trending data related to findings and facilitates timely turnaround of audit results.
11. Prepares written summaries of audit results for purposes of reporting potential fraud, waste, abuse and/or overpayment.
12. Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner.
13. Identifies potential provider fraud through review of claims data, complaint referrals, and application of rules, healthcare coding practices, and fraud detection software.
14. Reviews provider billing practices to investigate claims data and compliance with State and Federal laws.
15. Analyzes provider data and identifies erroneous or questionable billing practices.
16. Interprets state and federal policies, Florida Medicaid, Children's Health Insurance Program, Marketplace, and contract requirements.
17. Determines and calculates overpayment/underpayment, appropriately documents and participates in steps to remediate.
18. Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.
19. Performs all other duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Written and verbal communication skills.
• Ability to organize and prioritize work with minimum supervision.
• Detail oriented.
• Ability to perform math calculations.
• Analytical and critical thinking skills.
• Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions.

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

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