Primary ResponsibilitiesMedical Record Auditing
- Perform routine and focused audits of provider documentation and coding.
- Review Evaluation & Management (E/M) coding accuracy.
- Audit preventive visits, Annual Wellness Visits (AWV), chronic care visits, transitional care management (TCM), and other specialty services.
- Ensure documentation supports billed CPT, HCPCS, and ICD-10-CM codes.
- Provide audit reports with education and corrective action plans.
Documentation & Coding Compliance
- Ensure complete and accurate provider documentation.
- Verify ICD-10 diagnosis specificity and risk adjustment coding.
- Review HCC coding accuracy for Medicare Advantage and value-based contracts.
- Identify documentation deficiencies and provide recommendations.
- Maintain compliance with CMS, AMA, OIG, and payer coding guidelines.
Medical Necessity ComplianceReview medical necessity and documentation for:
- Laboratory testing
- Allergy testing and immunotherapy
- Diagnostic imaging
- Pulmonary function testing (Spirometry)
- EKG
- Ultrasound
- Vascular studies
- Sleep testing
- TM Flow
- Other diagnostic services
Ensure services meet payer coverage policies and Local Coverage Determinations (LCDs).
Revenue Integrity & Missed Billing Opportunities
- Identify under-coded encounters.
- Identify missed billable services.
- Review appropriate use of preventive and problem-oriented visit combinations.
- Monitor modifier utilization.
- Identify missed opportunities for:
- Annual Wellness Visits
- Advance Care Planning
- Chronic Care Management (CCM)
- Transitional Care Management (TCM)
- Remote Patient Monitoring (RPM)
- Principal Care Management (PCM)
- Behavioral Health Integration (BHI)
- Care Coordination services
- Recommend workflow improvements to maximize compliant reimbursement.
Value-Based Care & Risk Adjustment
- Audit HCC capture and diagnosis recapture.
- Ensure appropriate chronic condition documentation.
- Review quality measure documentation (MIPS, HEDIS, STAR, MSSP, ACO, PC Flex, and Medicare Advantage).
- Collaborate with Population Health and Clinical Quality teams to improve coding accuracy and quality performance.
- Identify opportunities to improve RAF scores while maintaining compliance.
Insurance & Regulatory Compliance
- Prepare providers for payer audits.
- Support responses to insurance medical record requests.
- Assist with Medicare, Medicaid, RAC, CERT, and commercial payer audits.
- Monitor compliance with CMS regulations and payer policies.
- Identify compliance risks and recommend corrective actions.
Provider Education
- Provide one-on-one provider education.
- Develop coding tip sheets and educational materials.
- Conduct coding workshops and documentation training.
- Share coding updates and payer policy changes.
Workflow Improvement
- Analyze clinic workflows to improve documentation quality.
- Partner with clinical operations to streamline coding processes.
- Recommend EMR optimization.
- Collaborate with Revenue Cycle, Population Health, and IT teams to improve coding efficiency and reduce denials.
QualificationsRequired
- Certified Professional Coder (CPC) preferred
- Certified Professional Medical Auditor (CPMA) strongly preferred
- Certified Risk Adjustment Coder (CRC) preferred
- Minimum 2 years of coding or auditing experience
- Strong knowledge of:
- CPT
- ICD-10-CM
- HCPCS
- CMS Documentation Guidelines
- Medicare regulations
- Commercial insurance policies
Preferred
- Experience in Primary Care, Internal Medicine, or Family Medicine
- Experience with Medicare Advantage and HCC coding
- Experience with Value-Based Care, MSSP, ACOs, MIPS, PC Flex, or Medicare Shared Savings Programs
- Experience using eClinicalWorks (eCW) or similar EMR
- Knowledge of Revenue Cycle Management
Salary: $30-35 dollars per hours.
Pay: $30.00 - $35.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
