Job Description

: JOB DESCRIPTION The Clinical Auditor performs reviews, analyzes, and codes documentation from medical records that determines payments. This position performs highly technical and specialized functions, and the primary function of this position is to perform a thorough review of patient encounters to assess for completeness and accuracy of provider documentation and ICD-10-CM, CPT and HCPCS coding. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines. ESSENTIAL CRITERIA: Bachelor's degree (or equivalent) in Nursing. NCLEX certification - Active(USRN) Able to apply analytical and critical thinking to record reviews. Required comprehensive clinical knowledge and strong clinical experience. All certifications/License should be active. DESIRABLE CRITERIA: Certified professional coder (CPC) - AAPC Auditing experience on US Medical Coding. Knowledge in Microsoft outlook/excel/word Exposure on 3M software and NLP tool. PRIMARY RESPONSIBILITIES: Performs clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding. Integrates coding principles in performance of medical audit activity and educates as needed on those principles Upon completion of medical record audit, compiles detailed findings and prepares client reports, when needed. Coordinates with client to ensure patient data is received and processed for all scheduled audit work Communicate proper volume to support invoicing. Provides feedback and process improvement recommendations to appropriate leadership team and participates in workgroups/committee meetings and process improvement solutions as required. Maintains professional license and certifications and attends training conferences/webinars as necessary to keep abreast of latest trends in the field of expertise. ADDITIONAL RESPONSIBILITIES: Participates in and/or leads inter-departmental process improvement initiatives. Identifies compliance risks and financial opportunities based on chart reviews. Prepares reports and executive summaries as required by management regarding audit results, process improvement recommendations, and systemic billing errors. Adheres to established productivity standards, participates in departmental performance improvement activities and work level. Communicates and works with all internal and external customers. Performs other duties as assigned.