Outpatient Facility Coding Compliance Auditor

Primary Responsibilities

• Perform coding compliance and quality audits in support of Optum Insight Provider's Compliance Program and client expectations
• Independently analyze and interpret clinical documentation from medical records
• Validate coding accuracy for outpatient facility, including E/M services, procedures, and modifiers
• Identify audit findings, calculate billing error rates, and perform root cause analysis to determine drivers of non-compliance
• Assess and evaluate the adequacy and effectiveness of corrective action plans, providing follow-up validation as appropriate
• Clearly document audit findings and articulate results tailored to the appropriate audience
• Prepare written audit analysis and summary reports, including compliance risk, trends, and recommended corrective actions
• Conduct ad hoc coding and billing audits as requested
• Provide compliance oversight of QA audit activities, ensuring consistency and adherence to established standards
• Audit vendor coders and auditors, including offshore staff
• Monitor and track evolving industry trends, regulatory updates, and government audit activities to identify potential coding and billing risk areas
• Research, develop, and present targeted education based on individual, team, and systemic audit findings

Required Qualifications

• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or Certified Outpatient Coder (COC)
• 5+ years of Outpatient Facility coding experience including: NCCI/OCE billing edits related to outpatient services coding and billing, ICD-10-CM and CPT (including CPT-4), ACEP Facility or similar Facility E/M matrix guidelines for outpatient facility code assignment
• 5+ years of Outpatient Facility audit experience, including surgery, observation, and emergency department, including: Strong industry knowledge of Medicare regulations and payment policies, including OPPS

Preferred Qualifications

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Professional Medical Auditor (CPMA)