The Manager of Audits and Coding Projects supports the supervision, management, evaluation, and improvement of operations related to coding education, audits, and denials. Leads the auditing team responsible for evaluating the appropriateness and medical necessity of services and procedures billed based on supporting documentation, as well as the appropriateness of ICD-10, HCPCS and CPT codes and modifiers. Oversees the review of clinical denials for technical and professional services. Provides strategic direction for the development of training materials for coders, physicians, clinical documentation specialists, and other healthcare personnel. Partners with vendors for external audits of coder and organization performance.
Bachelor's degree or Equivalent Experience.
Specific Requirements and Preferences
Coding certification required
Minimum Work Experience
5 years of hospital auditing and coding experience with Bachelor’s degree OR 9 years of hospital auditing and coding experience with Associate’s degree.
- Strong understanding of coding processes and their relation to the overall Revenue Cycle data flow/third party
- Knowledge of accepted medical abbreviations and their meanings
- Knowledge in the use of specialized references such as the ICD-10-CM/PCS and CPT-4 books, medical dictionaries and
- Proficiency with Microsoft Office product suite
- Ability to communicate professionally with physicians, third party payers and other organization members about to coding
principles and processes
- 3M and/or Cerner Millennium experience strongly preferred
Audits and Coding
1.Oversee routine retrospective and prospective professional and technical billing audits, specialized and focused audits, and other audits as directed by the Director of Revenue Integrity.
2. Oversee preparation of written reports of audit findings and recommendations to hospital leadership and staff as appropriate.
3. Conduct risk assessments to define audit priorities by evaluating previous audit findings, management priorities, ICD and CPT code utilization patterns, national normative data, CMS and Medicaid initiatives, and healthcare industry best practices.
4. Maintain up-to-date knowledge of healthcare billing and coding compliance requirements, practices and trends and ensure teams’ compliance.
5. Maintain knowledge of current government and other third party payor billing and documentation requirements.
6. Oversee analysis of coding-related denials and lead efforts to resolve and learn from trends.
7. Assist in management of requests that come from Revenue Cycle teams related to coding questions on coding guidelines and denials, escalating as needed, and conducting appropriate research.
8. Analyze process improvement opportunities for coding team to identify denial risks mid-cycle.
1. Oversee professional and technical procedure and diagnosis coding education and training for coders, physicians, NPPs, clinical documentation specialists. and other healthcare personnel.
2. Oversee all activities related to the training programs, including curriculum development, job aids, testing methodology, software and delivery, exam development/delivery, employee competency metrics, certifications and development needs.
3. Provide project management/leadership for all coding training programs as they are requested throughout the enterprise.
4. Determine Key Performance Indicators and create/analyze metrics to determine the impact of training initiatives and ensure goals are met.
5. Perform analysis of CNMC coding and productivity data against industry benchmarking standards as applicable.
6. Research coding guidelines when conflicts arise within current policies and procedures.
7. Research updated coding information as it becomes available annually and mid-year; summarize/share changes impacting Revenue Integrity staff members.
1. Role model expertise in communication through collaboration with the Director, Managers, physician and hospital management, and staff.
2. Work collaboratively with all Directors, Managers and Physicians to achieve optimal clinical code capture for appropriate SOI scores and DRG assignments.
3. Provide performance feedback in a constructive manner to staff.
1. Develop and implement systems to monitor performance and quality of audits and educational materials.
2. Develop and provide educational programs for auditors, denials analysts, and educators.
3. Coach, develop and encourage staff in designated areas of supervision.
4. Participate in human resource education programs including customer service, management and supervision and other industry-wide programs impacting health care.
5. Complete performance evaluations on all assigned staff in a timely manner.
1. Greet staff cordially and acknowledge positive productivity .
2. Actively participate in the resolution of challenges that impact negatively on the department.
3. Proactively demonstrate customer-oriented behavior and act as a role model for all staff.
Organizational Accountabilities (Leader)
1. Set and clearly communicate team goals and priorities in alignment with departmental goals and budgets
2. Develop the budget and assign resources to meet the team goals
3. Provide the resources and guidance required for employees to perform effectively
4. Develop procedures to ensure high safety and quality, and course-correct as needed
5. Identify customers’ needs and ensure service excellence in meeting those needs
1. Be the link between the department and the team in defining the strategies to meet team goals
2. Provide prompt and clear feedback to staff and support their performance
3. Ensure team adherence to organizational regulations
4. Manage the working environment to promote productivity and motivation
5. Represent the team in clearing obstacles to high performance
6. Hire staff and develop their capabilities
7. Monitor and promote strong employee engagement
1. Encourage and share new ways of making the right work easier to do
2. Recognize and share incremental improvements in operations
3. Promote the success of organizational and department initiatives by clearly aligning programs to the mission