Coding Integrity Auditor

Summary of Job

Responsible for upholding the standard for code review functions in the setting of claims review, grievance and appeal, and new medical policy implementation. Identify inconsistencies between CCI & EH reimbursement policies and claim which directly impact claim payment (i.e. authorizations) and responsible for working with leadership to bring to resolution. Perform audit of suspended and appealed claims reviewed by coding staff. Perform audits of outlier providers for accurate coding practices and documentation requirements.

Responsibilities:

• Audit internal and external business partners (processes and results) for accurate claim coding reviews for various programs, pre- and post-payment.
• Audit claim reviews and medical records to ensure accurate adjudication; review decisions from Coding Integrity team; provide feedback, results, and recommendations to management.
• Review reporting for outlier provider claims; request patient medical records to assign diagnoses, treatments, and surgical and non-surgical procedures for facility and medical services for coding and payment integrity.
• Provide direct education to the business and provider offices as needed to facilitate an understanding of correct claim coding, use of CPT, ICD-10, HCPCS, etc.
• Perform audits of changes to coding introduced by new medical policies, reimbursement policies, regulatory changes, and business requirements on a quarterly basis.
• Participate in RPC, RPCW, Medical Policy Committee (MPC) and Medical Policy Committee Workgroup (MPCW) as added Coding Integrity representation at meetings; ensure that decisions are appropriate and will result in accurate claim reimbursement.
• Identify reimbursement and coding variances from industry standards and brings to leader's attention.
• Provide support for internal and vendor edit reviews and provider contracts.
• Perform related tasks as directed or required.