Medical Coding Auditor

Description

Position Summary:

The Medical Coding Auditor conducts audits to provide investigative support related to potential fraud, waste, abuse and/or overpayment. Through post payment medical records review, the Medical Coding Auditor ensures appropriate coding on claims paid and maintains compliance documentation of any fraud, waste or abuse identified based on coding guidelines and regulatory and contract requirements.

Essential Duties and Responsibilities:

1. Performs post payment medical record review audits of claims payments to identify potential fraud, waste, abuse and/or overpayment. 
2. Completes and maintains detailed documentation of audits including but not limited to coding guidelines reviewed, medical necessity documentation, decision methodology, and monetary discrepancies identified. 
3. Coordinates overpayment recoveries with the Fraud Investigative Unit Manager. 
4. Responsible for assisting the Fraud Investigative Unit Manager with potential fraud, waste or abuse investigations requiring medical coding expertise, participating in external audit requests, and special projects as needed. 
5. Coordinates, conducts, and documents audits as needed for investigative purposes. 
6. Prepares written reports or trending data related to findings and facilitates timely turnaround of audit results. 
7. Prepares written summaries of audit results for purposes of reporting potential fraud, waste, abuse and/or overpayment.  
8. Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner. 
9. Identifies potential provider fraud through review of claims data, complaint referrals, and application of rules, healthcare coding practices, and fraud detection software.     
10. Reviews provider billing practices to investigate claims data and compliance with State and Federal laws. 
11. Analyzes provider data and identifies erroneous or questionable billing practices.   
12. Interprets state and federal policies, Florida Medicaid, Children’s Health Insurance Program, and contract requirements.
13. Determines and calculates overpayment/underpayment, appropriately documents and participates in steps to remediate. 
14. Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.
15. Performs all other duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Written and verbal communication skills.
• Ability to organize and prioritize work with minimum supervision.
• Detail oriented.
• Ability to perform math calculations.
• Analytical and critical thinking skills.
• Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs. 
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear.   The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Qualifications

• Medical Coder certification from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) must have.
• Prior experience in Medicaid claims role and/or post payment medical coding auditor role preferred.
• Knowledge of Medicaid rules, claims processing, medical terminology and coding principles and practices.
• Knowledge of auditing, investigation, and research.
• Knowledge of word processing software, spreadsheet software, and internet software.
• Manage time efficiently and follow through on duties to completion.