The Coding & Documentation Compliance Specialist conducts detailed audits and investigations to ensure accurate medical coding and documentation compliance with federal and state regulations. They analyze claims, research eligibility and payment issues, and assist in anti-fraud initiatives by identifying overpayments and supporting investigations. Additionally, they provide educational programs to staff regarding compliance and audit findings.
POSITION SUMMARY/RESPONSIBILITIES
Functions under the direct supervision of the Special Investigations Unit (SIU) Manager. Performs at the advanced skill level of a Coding Specialist. Is adept at data collection and statistical report generation. Demonstrates individual judgement, initiates work improvement methods. Will conduct administrative investigations related to fraud and abuse. Will conduct research related to eligibility, claims payment, benefits, prior authorization/referrals and contract review. Responsible for conducting and reviewing audits to assess the quality of coding and documentation to ensure compliance with federal and state laws and regulations. Responsible for researching and compiling documentation that may be reported to external regulatory and law enforcement agencies. Research and audit for accurate provider and facility payments. Identifies overpayments to provider. Assists provider, employee and contractors with the Community First Health Plan's anti-fraud program. Conducts routine education programs for staff and physicians to communicate findings from investigations, coding and documentation audits.
EDUCATION AND EXPERIENCE
High school diploma or its equivalent is required. Five years of experience with ICD-9-CM/DRG assignment, chart auditing, and CPT4 code assignment is required or only two years of experience if candidate has successfully completed a Certified Coding Program or Health Information Management Program. Must be knowledgeable of ICD-10. Must be knowledgeable of Microsoft Office products.
medical coding, documentation compliance, fraud investigation, claims auditing, ICD-10, CPT coding, health information management, provider payments, regulatory compliance, anti-fraud program
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