Medical Coding Auditing Specialist 1 1

About the role

Serco is continuing support to the Defense Health Agency (DHA) Medical Coding Program Branch (MCPB). The MCPB’s essential mission is to improve the accuracy and quality of medical coding and documentation across DHA in support of the DHA mission. Medical Coding Auditing consists of a systematic, unbiased, independent examination of medical documentation and coding to validate that all codes entered into the Military Health System (MHS) systems are in conformity with official coding policies, regulations, requirements, and standards.

The work encompasses all 400 Military Treatment Facilities and Dental clinics assigned to DHA Markets and may include multiple conference calls, virtual meetings, and onsite visits to DHA organizational elements inside the continental United States (CONUS) and outside of the continental United States (OCONUS).

Responsibilities

• Perform routine or standard audits of all MTFs and Dental clinics assigned to DHA Markets, such as the Data Quality Management Control (DQMC) audit.
• Provide direct support to the DHA-MCPB to develop an annual work plan of medical coding audits based upon identified enterprise risk factors.
• Perform targeted coding and/or documentation audits of DHA Markets, DHARs, medical service lines or specialties, MTFs, or individuals when directed.
• Provide direct support to the DHA-MCPB in performance of medical coding audits used in Government surveillance of other DHA medical coding contracts.

Education

• An associate’s degree or higher in Health Information Management or Healthcare Administration or biological science; OR
• A university, college, or technical school certificate in medical coding; OR
• At least 30 semester hours’ university/college credit of a grade of “C”, “Pass”, or better, that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology; OR
• Successful completion of an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) online or in-person coding exam preparation course that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology; OR
• Successful completion of a training course beyond apprentice level for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision.

Mandatory Skills

• Advanced knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM), and Procedural Coding System (PCS); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).
• Advanced knowledge of reimbursement systems, including Prospective Payment System (PPS) and Diagnostic Related Groupings (DRGs); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS).
• Advanced knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.
• Practical knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology); and revenue cycle management concepts.
• Thorough understanding of Government rules and regulations regarding medical coding, reimbursement guidelines, and healthcare fraud; commercial reimbursement guidelines and policies; coding audit principles and concepts, and potential areas of risk for fraud and abuse. Includes, but is not limited to: The Federal Register, Center for Medicare, and Medicaid Services (CMS) Local Coverage Determinations and National Coverage Determinations (LCD and NCD), National Correct Coding Initiative (NCCI) guidance, manual, and edits, Internet-Only Manuals (IOMs), and HHS-OIG publications and reports.
• Practical knowledge of revenue cycle management, project management concepts, business analysis, training methods, clinical documentation improvement, and continuous process improvement processes.
• Practical knowledge of Current Dental Terminology (CDT).

Certifications

• Professional Services Coding Certifications: ONE of the following recognized professional coding certifications: Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Professional Coder (CPC); or Certified Coding Specialist – Physician (CCS-P). Other professional coding certifications will be considered by the DHA-MCPB on a case-by-case basis.
• Institutional (Facility) Coding Certifications: ONE of the following recognized institutional coding certifications: Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Inpatient Coder (CIC), or Certified Coding Specialist (CCS). Other institutional coding certifications will be considered by the DHA-MCPB on a case-by-case basis.
• Additional Coding Auditing Certifications: EACH of the following:
  • AAPC: Certified Professional Medical Auditor (CPMA); AND
  • National Alliance of Medical Auditing Specialists (NAMAS): Certified Evaluation and Management Auditor (CEMA).
• Other medical coding auditing certifications will be considered by the DHA-MCPB on a case-by-case basis.
• Continuing Education Requirements: Medical coding personnel shall maintain the required continuing education hours in order to maintain current and proper national certification(s) requirements for this position at no expense to the Government.

Experience Requirements

• A minimum of seven (7) years of medical coding and/or auditing experience in four (4) or more medical, surgical, and ancillary specialties within the past 15 years. A minimum of one (1) year of performance in the specialty is required to be qualifying.
• Four (4) years of the seven (7) years of required coding experience must involve medical coding auditing functions. Auditing functions include development and execution of audit plan, conducting audit according to audit plan by reviewing required documentation and determining compliance with audit standards, communicating with stakeholders during all phases of audit, and reporting on audit findings.
• Coding experience should include inpatient facility and ambulatory surgery areas.
• Coding, auditing, and training exclusively for specialties such as home health, skilled nursing facilities, and rehabilitation care will not be considered as qualifying experience.
• Coding experience limited to making codes conform to specific payer requirements for the business office (insurance billing, accounts receivable) is not a qualifying factor.

Pre-employment Testing

• Prospective candidates must pass a pre-employment Medical Coding Compliance Specialist Test, with a score of 70% or better.
• If the candidate is an incumbent on a current or prior DHA or Military Department (MILDEP) contract, the test will be waived IF the incumbent has demonstrated satisfactory performance and otherwise meets the qualifications for the position.

Developmental Classification

A Medical Coding Compliance Specialist candidate that does not meet all required certifications may be accepted in a “developmental classification” at 90% of the Full Performance salary. Employees assigned to a Developmental Classification will be required to sign a memorandum of agreement (MOA) with Serco agreeing to eliminate the deficiency within an agreed to timeframe.