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Coding Auditor Educator - Outpatient

Company: Highmark
Location: Harrisburg
Posted on: March 25, 2020

Job Description:

Company :

Allegheny Health Network

Job Description :


Performs all related internal, concurrent, prospective and retrospective coding audit activities. Reviews medical records to determine data quality and accuracy of coding, billing and documentation related to DRG's, APC's, CPT and HCPCS Level II code and modifier assignments, ICD diagnosis and procedure coding, DRG/APC structure according to regulatory requirements. Reports findings both verbally and in writing and communicates results to affected areas. Uses information to generate topics for education, training, process changes, risk reduction, optimization of reimbursement with new and current coders in accordance with coding principles and guidelines. Promotes cooperation with CDMP and compliance programs to improve documentation which supports compliant coding. Interacts with external consultants regarding billing, coding and/or documentation and evaluates their recommendations and/or teaching plans in accordance with federal and state regulations and guidelines


  • Plans and conducts audits and reports on the documentation, coding and billing performed at AHN entities. Reviews, develops and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements. Provides written audit guidance. Participates with management in the assessment of external audit findings and responds as needed. Attends meetings and interacts with management to resolve issues and provide advice on new programs. Provides guidance to system entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc. Determine appeal action, prepare appeal letter follow up and identify education issues. (20%)
  • Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact and profitability. Conducts education/training or works with external resources to present final audit findings to department staff, physicians and appropriate individuals. (20%)
  • Validates the ICD CM, ICD PCS, CPT and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements. Performs periodic claim form reviews to check code transfer accuracy from the abstracting system and the chargemaster. (10%)
  • Is responsible for or works with external resources to create and monitor inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends and variations in the facilities frequently assigned DRG/APC groups. Once identified, evaluate the cases of the change or problems and takes appropriate steps to effect resolution. (10%)
  • Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD CM ICD PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC. (10%)
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines. Assures compliance with the coding guidelines and regulatory requirements. (10%)
  • Performs other duties as assigned or required including training/mentoring of new staff, performing audits and research related to special projects and providing coverage for coding manager(s). (10%)
  • Depending on location provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology and disease processes as it relates to the DRG/APC and other clinical data quality management factors. With technical direction and assistance from management, designs and implements coder education program, continuing education programs and Medical Staff education programs. Establishes and monitors performance and maintains appropriate documentation thereof. (10%)

    • High school diploma or GED.
    • Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist certification.
    • Current driver's license.
    • 5 years experience in hospital coding and/or auditing, as well as, education techniques and methods
    • In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems. Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective Payment System and Coding Clinic References. Current working knowledge of encoder, grouper, abstracting and other related software. Strong analytical and communication skills.
    • Internal transfer and promotion candidates may have a minimum of three years' of experience in the above along with the required knowledge
      • Associated Degree.
      • 3 years experience with claims processing and data management
      • Past auditing and strong education/training background in coding and reimbursement.

        Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

        EEO is The Law

        Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf )

        We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

        For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

        California Consumer Privacy Act Employees, Contractors, and Applicants Notice


        Total Rewards Program
        In addition to competitive pay rates and flexible career growth, we show our employee appreciation through a comprehensive Total Rewards package, including:
        • Medical and prescription drug, dental and vision coverages, including family and domestic partners
        • Health Saving and Flexible Spending Accounts
        • Life, AD&D and disability insurance
        • Retirement benefits
        • Paid time off, including paid holidays and a volunteer day
        • Tuition reimbursement
        • Volunteer opportunities
        • Work/life programs, including Employee Assistance Plans
          Wellness Resources and Programs
          Employees have access to the following wellness programs and resources:
          • Onsite employee health center with same-day sick appointments, physical therapy and pharmacy services at major campuses
          • 24/7 telephone access to health and wellness coaching to achieve personal goals
          • Fitness center access for all employees inclusive of showers, lockers, and group exercise classes at major campuses
          • 100% coverage for preventive exams, including onsite flu shots
          • Incentive program that rewards employees with reduced health insurance premiums
          • Onsite chef-led cooking classes and tastings at major campuses
          • Departmental physical activity challenges to build camaraderie and reward employees
          • Sit-to-stand workstations, as well as personal ergonomic desk consultations
          • Onsite seated massage and stress management classes, including yoga and meditation at major campuses
          • Work-life resources, such as employee discounts and financial counseling services
          • Secure bicycle parking at major campuses
          • Environmentally healthy workplace, including energy-efficient buildings and eco-friendly product use

Keywords: Highmark, Harrisburg , Coding Auditor Educator - Outpatient, Accounting, Auditing , Harrisburg, Pennsylvania

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