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Responsible for performing quality inter-rater review audits of medical records coded by internal team to ensure the ICD-10 codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures.
Job Responsibility:
Perform quality inter-rater review audits of medical records coded by internal team
Ensure ICD-10 codes submitted to CMS for risk adjustment are appropriate, accurate, and supported
Support coding judgment using industry standard evidence and tools
Communicate evidence across stakeholders
Lead dispute resolution
Mentor and provide education to internal staff based on audit findings
Communicate audit process and results to appropriate departments and management
Conduct process audits to ensure compliance
Identify and recommend opportunities for process improvements
Work independently and in cross functional teams
Adhere to stringent timelines
Meet coding accuracy and production standards
Monitor own work to help ensure quality
Act in ethical manner as required under HIPAA
Serve as training resource and subject matter expert for ICD coding and documentation
Apply AHA Coding Clinic guidance
Remain current on educational training and requirements
Perform other related duties as required
Requirements:
CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) and CRC (Certified Risk Adjustment Coder) required
Experience with International Classification of Disease (ICD) codes required
Minimum of 3 years recent and related experience in medical record documentation review, diagnosis coding, and/or auditing
Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories (HCC) required
Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications)
BA/BS or equivalent experience
Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 3 years for CPC
5-8 years encompassing additional credentials and/or application of credentials
Nice to have:
CPMA (Certified Professional Medical Auditor), CDEO (Certified Documentation Expert Outpatient) or CPC-I (Certified Professional Coding Instructor) preferred
Excellent analytical and problem solving skills
Superior communication, organizational, and interpersonal skills