SIU Code Auditor

Responsibilities

• Perform detailed reviews and audits of medical records to verify the accuracy of coding and charges for services provided.
• Review provider documentation and professional services using ICD-10, CPT, HCPCS, and applicable federal, state, local, payer, Medicare, Medicaid, LCD, NCD, and internal policy requirements.
• Investigate and support findings of potential fraud, waste, or abuse by reviewing clinical and coding investigative summaries.
• Provide feedback and recommendations to investigators and management.
• Identify aberrant billing patterns, trends, and indicators of fraud, waste, or abuse.
• Recommend providers for further review, conduct root cause analysis as needed, and suggest process or program improvements to leadership.
• Meet with providers to discuss audit findings and improvement opportunities.
• Work closely with clinical teams, coding teams, Medical Directors, external partners, and providers to support accurate billing and effective case resolution.
• Aid in claim denial reporting, respond to regulatory agency complaints, support required fraud reporting to state and federal agencies, and recommend to members, providers, or employee education based on findings.
• Manage daily case review assignments with a strong emphasis on quality, provide regular updates to department leadership and senior management, maintain current knowledge of coding guidelines related to professional services, and perform other duties as assigned.

Qualifications

• Bachelor’s degree preferred or equivalent experience, and prior experience in healthcare.
• Certified Professional Coder (CPC) and/or Certified Coding Specialist (CCS) is required.
• Certified Evaluation and Management Coder (CEMC) or Certified Professional Medical Auditor (CPMA) is a plus.
• 3-4 years of relevant experience.
• Demonstrated proficiency in medical record audits and analysis and ICD-10CM/CPT coding methodology, HCPCS Coding systems and guidelines and knowledge and understanding of medical terminology.
• Knowledge of billing and other coding edits, as well as Centers for Medicare and Medicaid Services (CMS) local and national coverage determinations, and managed billing regulations.
• Strong quantitative, analytical, interpersonal, written and communication skills.

Pay

$87,500 annually, reflecting what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.