GENERAL OVERVIEW:
Senior most coding auditor who evaluates medical records to determine the accuracy of coding, billing and documentation related to DRG, OPPS and outpatient claims. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, process changes and risk reduction. Provides guidance to System entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Interacts with external consultants regarding, billing, coding and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines.
ESSENTIAL RESPONSIBILITIES
- Audits and reports on the documentation, coding and billing performed at System entities. (25%)
- Reviews, develops and delivers training programs and educational materials which address deficiencies identified in the audits. (25%)
- Consults with management. Provides written guidance. Participates with management in the assessment of external audit findings and responds as needed. Attends meetings and interacts with management to resolve issues and provide advice on new programs. (20%)
- Maintains coding knowledge and billing regulations associated with DRGs, CPT coding, ICD diagnosis and procedures coding and changes in CMS regulations. (20%)
- Acts as mentor and subject matter expert for staff. (5%)
- Performs other duties as assigned or required. (5%)
QUALIFICATIONS
Minimum
Preferred
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$34.29
Pay Range Maximum:
$54.25
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
