Professional Coding Compliance Auditor

Job Title

Compliance Audit And Analysis

Job Description

Primary function: Reporting to the Manager, Compliance Audit and Analysis, develops and executes audit, monitoring, and education for professional billing, coding and documentation programs that confirm compliance, identifies reimbursement implications, and provides billing providers with relevant and timely information regarding audit results and risk areas. Serves as a resource for providers on professional billing and coding. Principal duties and responsibilities include:

• Preparing and overseeing professional billing and coding components of the Compliance work plan reflecting scheduled activities and target dates.
• Leading focused audits and reviews to assess adherence with professional billing compliance policies, legal and regulatory requirements, and to identify and evaluate risk areas.
• Assisting in development of organizational compliance auditing and monitoring activities for professional billing and coding, including periodic reviews of the individual department auditing and monitoring functions.
• Coordinating sample reviews to ensure codes that were billed are properly supported by appropriate provider documentation.
• Creating audit result reports to be reviewed with providers.
• Organizing and scheduling audit findings/education sessions with providers to review audit results.
• Conducting sample and focused reviews to ensure provider coding and billing is compliant with government and payor guidelines.
• Analyzing and reviewing medical record documentation and billing data for all pertinent internal and external audits.
• Collaborating with clinical and administrative staff and leadership to ensure audit results are disseminated and understood.
• Managing investigations and audit findings in MDAudit and communicating with the Manager, Compliance Audit and Analysis if audit findings need to be escalated and entered into the Departments issues tracking system.
• Supporting professional billing compliance education including auditing, trending, and feedback to providers and professional coders.
• Managing and fostering relationships with internal professional coders, coding educators and managers and third-party clinical reviewers.
• Assisting with development and delivering educational and training programs for professional billing and clinical compliance based on the latest Federal and State regulations to appropriate providers and caregivers.
• Collaborating with other staff who may be conducting focused professional billing compliance audits and/or other special projects included in the annual departmental work plan.
• Maintaining required credentials, participating in continuing education opportunities to remain current with billing and coding compliance best practices.
• Actively participating in departmental meetings and activities, attending meetings and in-service/educational programs and other activities as requested.
• Maintaining confidentiality of patient/members and staff information.
• Performing assigned work safely, adhering to established departmental safety rules and practices; reporting to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
• Performing other related duties as required.

Education and Experience Requirements

- Current Professional Coders (CPC) or other relevant and industry-recognized certification required.

- Minimum of three (3) years of experience with audit activities required.

Preferred Experience:

- Bachelors degree preferred.

- Certification in Healthcare Compliance preferred.

Knowledge, Skills, and Ability Requirements

- Knowledge of legal, regulatory, and policy compliance issues related to coding, billing, procedures, and documentation.

- Ability to clearly communicate coding information, including the results of coding compliance audit activities.

- Proficiency in root cause analysis, critical thinking, and gaining acceptance of recommended solutions.

- Team player and understands role in relationship to others.

- Strong interpersonal and communication skills.

- Clear, concise, and persuasive writing and presentation skills.

- Strong orientation to deadline and detail.

- Strong organizational and project management skills.

- Working knowledge of computer software Word, Access, Excel, PowerPoint; as well as EMR.

- Knowledge of healthcare financial management principles/practices.

- Ability to work in highly matrixed environments.

- Ability to be flexible and adapt to change.

- Proficient in MDAudit Enterprise software and Epic electronic health record systems.

- Thorough knowledge of coding documentation improvement practices.

- Thorough knowledge and understanding of billing, coding, and documentation requirements, Federal and State regulations, unbundling edits, medical necessity, clinical best practices, and professional billing requirements.

Physical Requirements

Medium Max 25lbs: up to 25 lbs., 0-33% of the work day (occasionally); 11-25 lbs., 34-66% of the workday (frequently); 01-10 lbs., 67-100% of the workday (constantly); Lifting 25 lbs. max; Carrying of objects up to 25 lbs.; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.

Environmental Factors

Factors affecting environmental conditions may vary depending on the assigned work area and tasks. Environmental exposures include but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste chemicals/gases/fumes/vapors, Communicable diseases, Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.

Additional Details

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare's Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.