Coding Auidtor Professional (Surgical Services)

Children's National Medical Center Silver Spring, MD
The Professional Coding Auditor will demonstrate expertise in professional services coding and billing compliance. The Professional Coding Auditor audits to determine billing integrity of professional fees including detection and correction of documentation, coding and billing errors and/or medical necessity of services billed. Audits consist of evaluation of the adequacy and accuracy of documentation in support of services billed including ICD-10/CPT/HCPCS and other third party payor codes, medical necessity of the services, reimbursement overpayments and underpayments, and compliance with other documentation, coding and billing standards. The Professional Coding Auditor applies standardized audit scoring methodology to consistently evaluate documentation and coding, and standardized audit findings methodology to report audit results. The Professional Coding Auditor will also serve as a subject matter expert for professional billing coding and assist in physician coding education as necessary.

Minimum Education

Associate's Degree

Specific Requirements and Preferences

With 5 years of coding experience in lieu of the degree requirement will be considered. .

Minimum Work Experience

4 years

Specific Requirements and Preferences

4 Years as a Certified Coder in the professional fee billing environment with at least 1 year of experience performing professional fee coding audits.Minimum of 4 years of professional fee billing/coding experience with pediatric coding experience strongly preferred. Additionally at least 1 year of professional fee billing audit experience is required with academic medical experience preferred. .

Required Certifications

Certification in Coding required.

CCS, CCS-P, CPC, CPC-P/H, or COC. CPMA and/or CEMA/C preferred.

Required Skills/Knowledge

* Interpret and apply documentation and coding rules and regulations along with professional fee charge capture and

reimbursement methodologies;

* Plan, conduct and perform professional fee billing audits;

* Work cooperatively with Medical Center administrative staff and physicians/NPPs;

* Manage diverse and conflicting priorities and projects effectively and meet deadlines;

* Maintain competence in and up-to-date knowledge of healthcare billing and coding compliance requirements, practices

and trends;

* Conduct detailed professional fee billing audits, reach independent decisions and logical conclusions and prepare report of


* Interpret medical records progress notes, hand written and electronic chart entries, provider orders, and other related


* Proficiency in the use of personal computers with Windows operating systems including Microsoft applications such as

Word, Excel, Outlook, PowerPoint and Access.

* Communicate effectively both verbally and in writing.

* Performs scheduled and unscheduled independent professional fee billing audits of professional fee documentation,

coding and medical necessity related to professional service providers such as physicians and NPPs (Non-Physician


* Conducts routine retrospective and prospective professional fee billing audits, specialized and focused audits, and other

audits as directed by the Director of Revenue Integrity.

* Evaluates the appropriateness and medical necessity of services and procedures billed based on supporting documentation.

* Evaluates the appropriateness of ICD-10, HCPCS and CPT codes along with modifier usage.

* Makes determinations of overpayments and underpayments and performs other related analysis and evaluations.

* Adheres to the defined audit timeline and audit protocol standards.

* Assists with development of the audit schedule.

* Identifies services to be audited.

* Applies consistent and standardized billing audit methodology for sample selection, scoring and benchmarking

development and reporting of findings.

* Prepares written reports of audit findings and recommendations to Children's Management and staff as appropriate.

* Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities, ICD and

CPT code utilization patterns, national normative data, CMS and Medicaid initiatives, and healthcare industry best


* Maintain knowledge of current Medicare, Medicaid and other third party payor billing and documentation requirements.

* Assist in education of physicians and NPPs in professional fee billing and documentation requirements.

* Assist in technical fee billing audits as required.