OP Coding Auditor

Job Description

Position Description:

The OP Coding Auditor is a member of the CGI Healthcare Compliance, Outpatient Coding Team, with responsibility for reviewing medical records to determine the accuracy of coding and reimbursement for clinical services rendered to beneficiaries of health plans, including Commercial and Government Clients. The OP Coding Auditor is charged with rendering appropriate, well-supported, and thoroughly-documented decisions which may result in the identification of improper payments (overpayments and underpayments) on paid claims on behalf of the client from various providers of clinical services, including but not limited to acute care, long-term acute care, acute rehabilitation, and skilled nursing facilities, as well as other provider types and care settings.
The OP Coding Auditor is prepared for the role through a detailed, well-defined training process, gaining knowledge and skills in methods for review of the medical record and other provider documentation, application of appropriate coding guidelines, and use of the documentation format tailored to the client’s requirements. Ongoing training and education are provided specific to audit processes, coding and reimbursement changes, and other topics as indicated. The review process may result in changes to the payment for previously rendered services, and decisions are rendered through a well-defined process which requires the Auditor to incorporate coding experience and knowledge, as well as critical thinking skills in order to assess available information and render a decision. The OP Coding Auditor reports to an OP Coding Team Leader, who provides support, feedback, and guidance to the Auditor. Audit performance review and quality assurance are provided through a well-defined review and quality management program.

Your future duties and responsibilities:

1. Reviews medical records to identify recovery opportunities on claims for outpatient facility, professional, and other allied health services.
2. Provides a detailed rationale, including supporting references, for every review resulting in an outpatient findings letter.
3. Correctly interprets and utilizes reference materials, including coding standards and guidelines, CPT Assistant, Coding Clinic for HCPCS, NCDs, LCDs, as well as client reimbursement and medical policies.
4. Provides ongoing feedback to the Edit Development team on claims selection criteria and new recovery concepts.
5. If the contract requires onsite review, interacts with Providers and other personnel in a professional manner.
6. Follows CGI policies and procedures and completes Red Carpet, timesheets, payroll, travel expense documents, and other corporate requirements in a timely manner.
7. Performs other duties as assigned.
8. Communicates timely with Team Lead regarding illnesses, appointments, vacation requests, changes in work schedule, performance barriers, and computer issues.
9. Complies with department standards regarding productivity and audit quality.

Required qualifications to be successful in this role:

1. The Outpatient Coding Auditor possesses current AHIMA or AAPC credentials (RHIT, RHIA, CCS-P, CPC, CPC-H/COC), along with robust critical thinking and problem-solving skills. The auditor demonstrates extensive knowledge of ICD-10-CM, CPT and HCPCS coding guidelines including appropriate use of modifiers, with a minimum of five years of outpatient surgical coding experience in the facility and/or professional setting. Experience coding specialty surgical areas including orthopedics, cardiology, spine and back, and/or interventional radiology is highly desired. The Outpatient Coding Auditor must have a moderate understanding of CMS’s Outpatient Perspective Payment System (OPPS) including APCs, NCCI, and OCE edits
2. Previous experience training and mentoring junior-level coders, and/or peer-review auditing is highly desired, as is familiarity with Charge Description Master (CDM). A solid working knowledge of computer functions and applications such as Microsoft Office (Outlook, Word, and Excel) and Windows operating systems is required to manage applications utilized in the CGI audit process. The auditor should have experience working with an encoder, preferably Trucode and be accustomed to reviewing medical records remotely. The ability to write a well-reasoned review in a narrative style, with correct spelling, grammar, punctuation, and sentence structure is required for success in this position. The auditor must be able to adapt to changing priorities in order to meet Client requirements and is required to meet department quality and productivity standards. The auditor may be required to travel for additional training and on-site reviews on an as-needed basis.
Other Information:
CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to skill set, level, experience, relevant training, and licensure and certifications. To support the ability to reward for merit-based performance, CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range for this role in the U.S. is $62,700.00 - $146,300.00.
CGI’s benefits are offered to eligible professionals on their first day of employment to include:
• Competitive compensation
• Comprehensive insurance options
• Matching contributions through the 401(k) plan and the share purchase plan
• Paid time off for vacation, holidays, and sick time
• Paid parental leave
•Learning opportunities and tuition assistance
• Wellness and Well-being programs

What you can expect from us:

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