Ambulatory Services Auditor​/CDS

The Ambulatory Services Auditor and Clinical Documentation Specialist I is responsible for conducting audits of outpatient, inpatient and ambulatory service medical documentation across St. Charles Health System to ensure compliance with ICD-10-CM and CPT-4 coding regulations, rules, and guidelines. This position will also provide education, feedback, and guidance to multiple parties, as needed. This position does not directly manage any other Caregivers.

• Conduct system-wide pre- visit or post-visit chart reviews of professional services to include both hospital and clinic/office settings of care.
• Audit and monitor all lines of system business for coding, to include outpatient, inpatient and ambulatory services.
• Perform audits on/for the HIM Professional Services Coding team and provide feedback and education as needed to ensure compliance with quality coding standards.
• Evaluate medical records to ensure the accuracy of clinical documentation to support the acuity of the patient, risk profiles for HCC capture and recapture, and diagnostic and procedural code integrity in compliance with ICD-10-CM and CPT-4/HCPCs rules and guidelines.
• Develop and update procedure manuals to maintain standards for correct coding.
• Assist in conducting system-wide education and training in coding of professional services.
• Assist in setting the direction for coding compliance and education.
• Assist in providing technical guidance to physicians and other departmental staff in identifying and resolving issues such as incomplete or missing records, or codes that do not conform to approved coding guidelines.
• Recommend process changes and improvements within departmental and operational policies and procedures or system changes to reduce losses or improve efficiency.
• Monitor trends and prepare reports on such topics as documentation or coding issues and denied claims, for review by senior auditors and or management.
• Supports the vision, mission, and values of the organization in all respects.
• Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
• Provides and maintains a safe environment for caregivers, patients, and guests.
• Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
• Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
• May perform additional duties of similar complexity within the organization, as required or assigned.

• Required:
  
  High school diploma or GED
• Preferred:
  Associates degree in Health Information Technology or related field

• Required:
  
  RHIA, RHIT, CCS-P, CPC, CPMA, CRC, RN, or LPN
• Preferred: CPMA CRC, RN, LPN

• Required:
  
  0-3 years of coding experience required, or an equivalent combination of education and experience. Knowledge of current Medicare regulations, including, MPFS, IPPS and OPPS.
• Preferred:
  Inpatient, Outpatient, and Ambulatory services coding preferred. Physician Evaluation and Management coding experience preferred.