PREFERRED HEALTH PARTNERS (PHP) is a multispecialty physician group practice specializing in outpatient healthcare services for the diverse populations of Brooklyn.
The Coding and Compliance Auditor will be responsible for auditing for Medicare Risk Advantage Diagnosis(s) coding needs as well as Evaluation and Management services for correct type and level of service as supported by chart documentation and in compliance with all federal rules and regulations. ESSENTIAL FUNCTIONS: 1. The Coding and Compliance auditor will audit records quarterly for each assigned provider of PHP and will meet with all providers failing to achieve an accuracy rate of 80% accuracy of all services reviewed. 2. Audits will be completed to ensure effective claims submission based on medical necessity of the visit and accurate code selection as supported by chart documentation for appropriate ICD-9-CM, CPT-IV, HCPCS, and modifier usage. 3. Develop various tools and reports to accurately track and trend all audit results and educational efforts, as they relate to coding. 4. Interface with internal and external customers, including physicians, ancillary medical staff, administration, consultants, payers on coding needs and requirements within the practice management environment.5. All Evaluation and Management audits will be performed on a pre-bill status, and any necessary changes will be corrected prior to claims submission. All Medicare Risk audits will be completed, post-claim submission and any diagnosis found and not appropriately supported and/or captured will be corrected and all corrections will be submitted to Emblem.6. Works with AR staff and, when necessary, the third party billing company to assist with coding questions on any coding related claim denials for appropriate resolution. 7. Identifies trends/issues in medical documentation or coding and recommends possible solutionsSKILLS REQUIRED: 1. Excellent oral and written communication skills, with the ability to effectively articulate complex and technical coding issues and concerns with relevancy and clarity. 2. Significant experience and competency in ICD-9, CPT, and HCPCS coding based on federal rules and regulations and documentation requirements.3. Demonstrated knowledge and experience with multiple payer requirements and significant experience of the health care industry particularly as it relates to understanding HMO/PPO functions and multi-physician specialty billing, in both a capitated and fee for service environment.4. Highly proficient in the use of various computer systems, particularly Microsoft Word, Excel, PowerPoint, Outlook. Experience in EMR and PMS systems preferred (particularly Next Gen) but not required.EXPERIENCE REQUIRED: A minimum of three (3) years coding experience is preferredEDUCATION REQUIREMENTS: - Minimum requirement of High School diploma or equivalency. - Completion of an approved coding and billing certification program. - CPC or CCS-P coding certification preferred. If hired without CPC or CCS-P certification, certification must be obtained within one year of employment date, to be reimbursed by PHP upon successful completion.