Sr. Medical Coding Auditor

Senior Medical Coding Auditor

The US Oncology Network is looking for a Senior Medical Coding Auditor to join our team at Texas Oncology. This full-time position will support the Revenue Cycle Department at our 3001 E. President George Bush Hwy Suite 100 location in Richardson, Texas. Typical work week is Monday through Friday 8:00a - 5:00p.

This position will be a Sr level position.

As a part of The US Oncology Network, Texas Oncology delivers high-quality, evidence-based care to patients close to home. Texas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. Our mission is still the same today—at Texas Oncology, we use leading-edge technology and research to deliver high-quality, evidence-based cancer care to help our patients achieve "More Breakthroughs. More Victories."® in their fight against cancer. Today, Texas Oncology treats half of all Texans diagnosed with cancer on an annual basis.

The US Oncology Network is one of the nation's largest networks of community-based oncology physicians dedicated to advancing cancer care in America. The US Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.

What does the Senior Coding Operations Quality Analyst do? (including but not limited to)

Under minimal supervision, performs comprehensive reviews and investigations involving coding, documentation, billing, reimbursement, systems, workflows, and operational processes. Reviews may originate within Coding. Operations or from business partners and organizational stakeholders requiring coding and operational expertise.

Evaluates concerns from all applicable perspectives to determine the root cause, scope, impact, and appropriate resolution. Determines whether identified concerns are related to coding, documentation, billing, system configuration, workflow, process design, staff or provider education, operational practices, payer requirements, or a combination of factors.

Conducts audits, investigative research, data validation, claim review, and medical record review before issuing findings or recommendations. Coordinates with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, and other departments as necessary to obtain complete information and resolve identified issues.

Tracks findings, recommendations, and corrective actions through completion. Validates that corrective actions effectively resolved the identified issue and communicates final outcomes to the appropriate stakeholders.

Supports and adheres to the US Oncology Compliance Program, including the Code of Ethics and Business Standards.

Responsibilities

Essential Duties and Responsibilities:

• Performs complex reviews and investigations involving coding, documentation, billing, reimbursement, systems, workflows, operational processes, and related quality concerns.
• Receives and evaluates review requests originating within Coding Operations or from organizational stakeholders requiring coding and operational expertise.
• Establishes the appropriate scope and review methodology based on the reported concern, potential risk, available information, and affected services or processes.
• Reviews medical records, provider documentation, coding, charges, claims, billing activity, system configuration, operational workflows, policies, procedures, and supporting data to determine the facts and circumstances related to each concern.
• Evaluates concerns from all applicable perspectives and does not limit the investigation to the initially reported issue or assumed cause.
• Determines whether the identified issue is related to coding, documentation, billing, reimbursement, payer requirements, system configuration, workflow, process design, training, staff activity, provider activity, or a combination of factors.
• Conducts focused audits, medical record reviews, claim reviews, data validation, coding validation, and other investigative activities necessary to confirm the concern and determine its scope.
• Researches applicable CPT, HCPCS, ICD-10-CM, CMS, Medicare Administrative Contractor, National Correct Coding Initiative, payer, regulatory, and organizational guidance.
• Distinguishes between the reported concern, validated finding, contributing factors, and root cause before communicating conclusions.
• Identifies the population, time frame, specialties, providers, locations, claims, charges, or workflows potentially affected by the issue.
• Assesses the potential coding, documentation, billing, reimbursement, operational, financial, and compliance impact of validated findings.
• Documents the concern received, investigative steps completed, evidence reviewed, findings, root cause, scope, impact, and recommended actions.
• Ensures conclusions and recommendations are supported by medical record documentation, data, authoritative guidance, system evidence, workflow validation, or other appropriate supporting information.
• Prepares clear and concise reports of findings and recommendations for Coding leadership and other appropriate stakeholders.
• Identifies patterns, trends, control weaknesses, system issues, documentation deficiencies, coding concerns, billing risks, workflow barriers, and recurring operational problems.
• Determines when additional departments or subject-matter experts must be involved and coordinates their participation in the review.
• Collaborates with Coding Operations, Audit Operations, Education, Operations, Revenue Cycle, Information Technology, Compliance, reimbursement, clinical leadership, providers, and other stakeholders to validate findings and determine appropriate next steps.
• Facilitates communication among involved stakeholders to clarify responsibilities, address dependencies, and prevent gaps in issue resolution.
• Develops or recommends corrective actions based on the validated root cause, identified risk, and affected process.
• Documents responsible owners, required actions, expected deliverables, and target completion dates based on leadership direction and the outcome of the review.
• Tracks corrective actions, process changes, system corrections, coding updates, education, rebilling activities, workflow changes, and other remediation efforts through completion.
• Follows up with responsible stakeholders regarding outstanding actions, unresolved concerns, and missed completion dates.
• Performs follow-up reviews to validate that corrective actions were implemented and effectively resolved the identified issue.
• Determines whether additional monitoring, education, auditing, system controls, or process changes are necessary to reduce the risk of recurrence.
• Escalates significant findings, potential risk, recurring issues, unresolved concerns, ineffective corrective actions, and missed remediation commitments to the appropriate leadership.
• Communicates final findings, actions taken, validation results, remaining risk, and closure status to the appropriate stakeholders.
• Ensures reviews are not closed until required actions have been completed, resolution has been validated, and the final outcome has been documented.
• Develops and maintains standardized review procedures, investigation tools, tracking methods, documentation requirements, report templates, and closure criteria.
• Recommends procedural improvements, system controls, workflow changes, monitoring activities, audit opportunities, and education based on review findings.
• Supports implementation of approved process improvements and monitors whether changes produce the intended result.
• Serves as a Coding Operations resource regarding professional coding, documentation, billing, reimbursement, payer requirements, audit methodology, operational workflows, and issue resolution.
• Presents findings and recommendations to providers, administrative leaders, Coding leadership, and other stakeholders as appropriate.
• Maintains complete, accurate, timely, objective, and defensible documentation supporting each review and its final disposition.
• Maintains current knowledge of coding guidance, payer policies, reimbursement requirements, regulatory updates, documentation standards, and industry changes.
• Maintains the confidentiality and security of patient, provider, employee, and business information.
• Meets established quality, productivity, documentation, and turnaround-time expectations.
• Assists with special projects and other coding, audit, reimbursement, system, workflow, or operational reviews as assigned.

Qualifications

Minimum Qualifications:

High school diploma or equivalent required. A four-year degree in Health Information Management, Healthcare Administration, Business, Finance, Nursing, or a related field is preferred. An equivalent combination of relevant education and experience may be considered.

Minimum of seven years of relevant experience in professional fee coding, coding audit, billing compliance, reimbursement, healthcare operations, or related revenue cycle functions required.

Minimum of three years of professional fee coding audit or complex coding review experience required. Experience must include independently reviewing medical records, determining findings, researching coding or payer guidance, documenting conclusions, and communicating findings to leadership or other stakeholders.

Demonstrated experience conducting investigations, performing root-cause analysis, validating findings, preparing written reports, coordinating with cross-functional stakeholders, and tracking issues through resolution required.

Experience reviewing multiple professional fee specialties is required. Experience in medical oncology, infusion, surgery, radiation oncology, evaluation