At DAP Health, we are committed to transforming lives and advancing health equity for all. As a leading nonprofit health care provider, we deliver compassionate, high-quality care to the diverse communities of the Coachella Valley and San Diego County. Our comprehensive services range from primary care to mental health, wellness programs, and beyond, with a focus on those who are most vulnerable. Joining our team means becoming part of a passionate, innovative organization dedicated to making a meaningful impact in the lives of those we serve. If you're looking for a dynamic and purpose-driven environment, we invite you to explore the opportunity to contribute to our mission.
Job Summary
The Certified Medical Coder & Auditor evaluates medical records and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines. They analyze claims and coding to recommend revenue enhancements and best practices. This position has been identified as a safety sensitive position that includes tasks or duties (i.e., driving) that the employer in good faith believes could affect the safety, health, or reputation of the Organization, participants, the employee performing the task, or others.
Supervisory Responsibilities: None
Essential Duties/Responsibilities
- Analyze medical information from medical records
- Accurately code diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements
- Consult with medical clinicians to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes
- Provide thorough, timely, and accurate assignments of ICD and/or CPT4 codes, MSDRGs, APCs, POAs, and reconciliation of charges
- Abstract clinical diagnoses and procedure codes and document other pertinent information obtained from the medical record into the electronic medical records
- Seek out missing information and create complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, attending physician, consulting physicians, and appropriate signatures/authorizations
- Refer inconsistent patient treatment information/documentation to coding quality analysis, supervisor, or individual department for clarification/additional information for accurate code assignment
- Provide quality assurance for medical records for all assigned records and/or areas and assure compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG), and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards
- Review patient bills for accuracy and completeness with third-party billing vendors
- Follow up on unpaid claims within standard billing cycle timeframe with third-party billing vendors
- Audit insurance payments for accuracy and compliance with contract discount
- Call insurance companies regarding any discrepancy in payments, if necessary
- Participate in calls with third-party billing vendors
- Work with DAP Health teams to ensure EMR and WQs are kept current and up to date
- As assigned, compile daily and monthly reports; tabulate data from medical records for research or analysis purposes
- Routinely audit and review medical claims for timely submission, accurate payment, and denial remediation
- Develop an internal claims auditing program for DAP Health’s coding practices and execute the program with regular frequency (e.g. monthly, quarterly)
- Audit claims for appropriate levels of services (CPT coding), preventable denials, and proper coding and make recommendations for revenue enhancements based on review
- Leverage coding and billing experience to identify best practices for clinicians, billers, and external claims management agencies
- Monitor notes, charts, and claims for fraud, waste, and abuse by reviewing trends by providers and CPT codes
- Act as DAP Health’s lead in managing work queues and JIRAs that impact the revenue cycle
- Support operations through managing escalated client complaints, issues, or questions concerning billing
- Access patient-protected health information as needed
- Perform other duties as assigned
