Medical Coding Auditor

Overview

Certified Medical Coder required (AHIMA, AAPC, or PMI).

Hybrid-Sunrise, Florida

The Medical Coding Auditor conducts audits to provide investigative support related to potential fraud, waste, abuse and/or over payment. Through post payment medical records review, the Medical Coding Auditor ensures appropriate coding on claims paid and maintains compliance documentation of any fraud, waste or abuse identified based on coding guidelines and regulatory and contract requirements.

• Performs post payment medical record review audits of claims payments to identify potential fraud, waste, abuse and/or over payment.
• Completes and maintains detailed documentation of audits including but not limited to coding guidelines reviewed, medical necessity documentation, decision methodology, and monetary discrepancies identified.
• Coordinates over payment recoveries with the Fraud Investigative Unit Manager.
• Responsible for assisting the Fraud Investigative Unit Manager with potential fraud, waste or abuse investigations requiring medical coding expertise, participating in external audit requests, and special projects as needed.
• Coordinates, conducts, and documents audits as needed for investigative purposes.
• Prepares written reports or trending data related to findings and facilitates timely turnaround of audit results.
• Prepares written summaries of audit results for purposes of reporting potential fraud, waste, abuse and/or over payment.
• Retrieves and compiles data across multiple information systems and provides needed information for internal and external customers in a timely manner.
• Identifies potential provider fraud through review of claims data, complaint referrals, and application of rules, healthcare coding practices, and fraud detection software.
• Reviews provider billing practices to investigate claims data and compliance with State and Federal laws.
• Analyzes provider data and identifies erroneous or questionable billing practices.
• Interprets state and federal policies, Florida Medicaid, Children’s Health Insurance Program, and contract requirements.
• Determines and calculates over payment/underpayment, appropriately documents and participates in steps to remediate.
• Determines priorities and method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.
• Performs all other duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

• Medical Coder certification from accredited source (e.g. American Health Information Management Association, American Academy of Professional Coders or Practice Management Institute) must have.
• Prior experience in Medicaid claims role and/or post payment medical coding auditor role preferred.
• Knowledge of Medicaid rules, claims processing, medical terminology and coding principles and practices.
• Knowledge of auditing, investigation, and research.
• Knowledge of word processing software, spreadsheet software, and internet software.
• Manage time efficiently and follow through on duties to completion.

• Written and verbal communication skills.
• Ability to organize and prioritize work with minimum supervision.
• Detail oriented.
• Ability to perform math calculations.
• Analytical and critical thinking skills.
• Ability to operate personal computer and general office equipment as necessary to complete essential functions, including using spreadsheets, word processing, database, email, internet, and other computer programs.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions.

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

The physical demands…