Under the direction of the Coding Compliance Manager, the Coding Compliance Auditor/Educator will play a key role in reviewing and analyzing post claim data for accuracy and compliance with federal and state coding guidelines and regulations. The Coding Compliance Auditor/Educator will review both inpatient and outpatient services, including, but not limited to office, hospital, and surgical procedures. The Coding Compliance Auditor/Educator will work closely with MCMF providers providing coding and documentation education as well as supporting/educating the coding team. In addition, the Coding Compliance Auditor/Educator will also work closely with the Coding Compliance Manager on discovered coding irregularities and needed action items.
Essential Functions and Responsibilities of the Job
Proficient in Microsoft Office suite
Proficient in Epic software
Strong analytical skills
Strong critical thinking skills
The ability to anticipate, research, and resolve problems/strong problem-solving skills
Strong understanding of the health care revenue cycle
Excellent communication skills with the ability to communicate information accurately and clearly
The ability to train and mentor coding team
The ability to build and maintain positive provider relationships
The ability to handle complex and confidential information with discretion
Provide excellent customer service and address a moderate amount of incoming email and phone calls
The ability to manage interpersonal relationships and effectively communicate with clinical partners and fellow business center teams
Strong work ethic, honest, and dependable
Personal time management skills – the ability to organize, prioritize, and multitask
Collaborative team player with the ability to adapt to the ever-changing healthcare environment
Professional demeanor at all times
Maintain patient confidentiality
Maintain a safe and orderly work area
Interact in a positive and constructive manner
Ability to be at work and be on time
Follow company and department policies, procedures, and directives
Essential Job Outcomes
In adherence with standard work, perform a variety of audits, including but not limited to, Coder Quality, Annual Provider, Coding Compliance Committee, Integration, and New Provider audits.
Assess coding accuracy and compliance with policies and procedures and identify areas of potential risk. Provide support for Coding Compliance Committee and Integration Committee through the preparation of summary reports.
In adherence with standard work, provide ongoing education to coders and MCMF physicians to maximize compliance and reimbursement. Represent the PBS and Coding Departments in on-site meetings and provide support and training for both new and established providers.
In adherence with standard work, follow Coding Compliance department standards and branding when communicating with clinical partners and fellow business center teams. Work collaboratively to solve billing and coding issues with Physician Billing Services Insurance and Customer Service Representatives.
Employ strong understanding of the healthcare revenue cycle, as well as a working knowledge of Medicare, Commercial, and HMO insurance, including the impact on reimbursement. Utilize medical reference resources and contacts to thoroughly research coding issues and maintain working knowledge of payment/reimbursement systems to ensure maximum reimbursement and coding compliance.
In adherence with standard work, analyze coding related denials to help identify and correct reimbursement deficiencies, to identify opportunities for coding optimization, education/training, and to deter non-compliant coding behaviors.
In adherence to standard work, analyze bell curve reports to determine whether there is variation from national averages and/or MCMF peers due to inappropriate coding, insufficient documentation, or missed revenue opportunity.
In adherence to standard work, perform new business coding risk analysis to report out on provider coding behaviors that may put revenue and compliance at risk for the organization.
In adherence with standard work, take responsibility for various projects as assigned by management, and perform any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of knowledge/ability.
Inspire the trust and respect of the coding team and help increase coder productivity and quality through on-going education and support, motivating the team to achieve both department and organizational goals.
Act as administrator of the MCMF audit manager tool.
Act as a collaborative partner to the Coding Manager to enhance overall coding team performance. In addition, act as a resource for PBS Managers, Practice Managers, Medical Group Directors, System Support and other staff.
“Other duties as assigned”
Minimum 5-years’ coding and auditing experience, along with extensive payer knowledge.
Ten- years’ healthcare background experience
Previous interaction with physicians and executive leadership
Expert knowledge of ICD10, CPT, and HCPCS
Strong knowledge of medical terminology, anatomy and physiology
Epic software experience required
Proficient Microsoft skill
High School diploma or GED required;
CPC, CCS or equivalent certification required;
Auditing certification highly desired
Internal Number: MEM003836
About MemorialCare Medical Foundation
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.