General Summary: Under general supervision, reviews and audits medical records to ensure that the documentation contained in the medical records justifies the data billed on the encounters. Using established methodology, determines omissions and measures timeliness of encounter submissions. Develop and perform ongoing compliance training throughout the organization, including the development of staff training. Provide ongoing advice and resources to management for compliance issues and process monitoring and improvement, and work with management to implement these improvements. Assist Leadership with the development and implementation of the annual Compliance Work plans.
Conducts reviews/audits of selected enrolled client’s medical records.
Compares medical records and encounter data submissions utilizing the Covered Service Guide; ICD10, CPT and HCPCs manuals guidelines and rules. Monitors correction of errors and tracks provider resubmissions to justify accurate coding of services provided.
Determines omissions and measures timeliness of encounter submissions.
Provides verbal and written technical assistance to clinical staff to resolve identified errors.
Validates encounter acceptance within the company’s claims system.
Provides education and training to clinical staff.
Works closely with other departments to ensure services being encountered are accurately documented for submission.
Prepares periodic and ad hoc reports.
Assists Quality Improvement staff in daily operations.
Identifies, coordinates and implements process improvement initiatives.
Prepares and presents presentations to upper management.
Prepares for audits and assists in the formulation of any corrective action.
Submits data validation monthly and quarterly reports.
Responsible for following any policies, procedures, and controls established by the organization, regarding access to, protection of, and the use of the PHI.
Experience – Three (3) years’ experience auditing and/or monitoring healthcare records. Minimum two (2) years’ experience in claims processing required. Experience in ICD10, CPT, HCPCS and UB04 coding required. Experience in quality management in behavioral health field preferred.
Certification – Claims Coding Certification from the American Academy of Professional Coders required.
Current, valid Arizona Driver’s License and 39-month Motor Vehicle Report and proof of vehicle registration liability insurance to meet insurance requirements.