Coding Audit Specialist, Health Plan

Facility: Remote WI • Location: Remote, WI • Shift: Day • Full time • Weekly Hours: 40.00

About the role

The Coding Audit Specialist conducts quality assurance activities to ensure the accuracy and integrity of risk adjustment data submitted to the Centers for Medicare & Medicaid Services (CMS) and Department of Health Services (DHS). This role identifies deficiencies and provides management with an analysis of outcomes and tools for improving accuracy in coding.

Responsibilities

• Audits medical record documentation to determine appropriate diagnostic coding for services provided, adhering to AMA CPT coding guidelines, ICD-9 & ICD-10 Coding Guidelines, CMS Medicare, HHS, and DHS BadgerCare Plus risk adjustment policy, and Hierarchical Condition Category (HCC) Coding.
• Develops, implements, and monitors a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange, and Medicaid/BadgerCare Plus member diagnosis documentation, in collaboration with risk adjustment leadership.
• Audits medical record documentation to ensure correct codes have been selected and to detect uncoded or miscoded diagnoses for Medicare Advantage, ACA/Exchange, and BadgerCare Plus member populations.
• Develops and maintains skills to accurately audit coding for visits (evaluation and management) and procedures documented by physicians, hospitals, and other providers across various specialties and subspecialties as it relates to HCC coding.
• Maintains knowledge of CPT coding rules, ICD-9 and ICD-10 codes, HCPCS codes, HCC coding, use of modifiers, documentation guidelines, CMS Policy requirements, and other reimbursement guidelines to ensure accurate documentation review and diagnosis code assignment.
• Reviews components of provider documentation and compares them with the requirements of the reported code(s) to verify that documentation supports the code(s).
• Formulates outcomes for each audit, identifying correct or incorrect coding to ensure findings are presented in a logical, concise summary.

Requirements

• High school diploma or equivalent required.
• Demonstrated knowledge of anatomy/physiology and medical terminology.
• Completion of courses in Current Procedural Terminology (CPT), ICD-9, and ICD-10 coding required.
• Associate Degree in coding and/or health-related field preferred.
• Three years of experience in a health insurance, compliance, quality assurance, or auditing-related position.
• Experience with ICD-9, ICD-10, CPT, HCC, and HCPCS coding.
• Knowledge of CMS guidelines affecting Medicare Advantage, HHS-ACA, and DHS/BadgerCare Plus members as related to revenue management.
• Demonstrated knowledge of Microsoft Word, Excel, and Access.
• Certified Professional Coder (CPC) and/or Certified Risk Adjustment Coder (CRC) certification awarded by the American Academy of Professional Coders required within one year of hire.

Pay

Salary Range: $21.50 - $34.50 per hour

Benefits

Sanford offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, benefits may include:

• Health insurance
• Dental insurance
• Vision insurance
• Life insurance
• 401(k) retirement plan
• Work/life balance benefits
• Generous time off package to maintain a healthy work-home balance

For more information about Total Rewards, visit sanfordcareers.com/benefits.