Remote Insurance Utilization Review Jobs in Raleigh, NC

General Description of the Job Class:

The Compliance Specialist Auditor will perform coding quality audits of inpatient records to assure appropriateness and accurate code assignments in accordance with Center of Medicare and Medicaid (CMS) guidelines and to provide ongoing feedback and identification of the education needs for the providers and staff.

Duties and Responsibilities

PRIMARY FUNCTION: Monthly QA Audits of PB coders.

Monitor data quality and optimal reimbursement to the hospital by performing retrospective quality audits for accurate coding of ICD-10-CM diagnoses or CPT-4 procedures (and appropriate use of modifiers) for professional and outpatient services using Center for Medicare and Medicaid coding guidelines, standards and regulations.

Should be able to adequately utilize coding resources to back up any findings within audit

Responsible for performing medical record reviews to ensure that documentation supports the assigned codes.

Performs focused/integrated audits; when necessary

Serves as subject matter coding expert

Collaborates with outside departments

Serves as the expert for coding questions

Identify coding and billing risk areas, report results to PB Operations for action plan

Analyzes coded records for compliance with federal, state and third party insurer rules and regulations and note trends.

Excellent verbal and written communication

Sets the tone for ethical behavior, actively models ethical behavior to set an example for others

Identifies issues and discusses them in a timely and constructive manner to obtain a rapid and effective resolution

Performs other related duties incidental to the work described herein and other related work as assigned.

HIGHLY SOUGHT AFTER SKILLS:

• HCC coding/auditing
• Multi-Specialty Coding/Auditing
• Examples:
• Interventional Radiology
• Cardiothoracic
• Ortho (Foot and Ankle Specifically)
• Critical Care
• Observation Services
• ED
• Edits/Denials
• Gen Surg
• Trauma
• Peds
• GI
• Anesthesia

• Good work ethic
• Strong sense of responsibility
• Ability to work independently

 Required Qualifications at this Level:

Education:

• High School Diploma, required

Experience:

• Four (4) years of coding review experience in applying compliance, auditing and coding principles as they relate to professional coding and billing
• Or equivalent combination of relevant education and/or experience.

Degrees, Licensure, and/or Certification:

• Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) and/or Certified Coding Specialist (CCS), required
•  Certified Risk Coder (CRC), Certified Professional Medical Auditor (CPMA)- Added bonus credentials

Knowledge, Skills, and Abilities:

Knowledge of:

• ICD-10-CM and CPT/HCPCS coding guidelines to effectively apply to outpatient diagnoses and procedures.
• Knowledge of prospective payment systems and thorough understanding of DRG/APC reimbursement methodologies and coding validation.
• Understanding of anatomy, physiology, pharmacology and medical terminology.

Ability to:

• Achieve thoroughness and accuracy in task completion
• Analyze detailed information to determine appropriate compliance with coding and reimbursement regulations
• Establish and maintain effective working relationships
• Communicate clearly and concisely
• Identify trends within audits

Systems

• Epic experience preferred; 3M 360 CAC, Audit Manager
• MS Office Applications (Word, Excel, Visio, Access, PowerPoint)

Distinguishing Characteristics of this Level:

All job performance relates to the strategic goals of DUHS and its entities.  All DUHS staff are expected to live Duke's Core Value: Caring for our patients, their loved ones and each other.  Demonstrating commitment to excellence, safety, integrity, diversity and teamwork.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.