Who We Are
With a mission to provide world-class healthcare to the underserved Asian community, Rendr is the leading primary care focused, multi-specialty physician group dedicated to serving the Asian population in New York City. Our over 200 providers take care of the health of approximately 200,000 patients at more than 100 clinical offices throughout Brooklyn, Manhattan, Queens, Staten Island and Nassau County.
Department: Compliance Auditing and Monitoring
Location: Headquarters – New York, NY
Position Summary
The Senior Risk Adjustment and Medical Coding Compliance Auditor works closely with the Corporate Compliance Officer to implement and maintain a system-wide effective compliance program through performance of coding and documentation quality audits. The Auditor is responsible for developing the process for conducting annual and periodic coding and documentation quality audits of medical records to ensure appropriate capture and support for CPT-4/HCPCS and ICD-10-CM codes, with an emphasis on ICD-10-CM codes that risk adjust under the CMS-HCC model. The Auditor will apply expertise in medical and risk adjustment coding to conduct coding and documentation quality audits, including identifying, tracking, and remediating discrepancies. The Auditor must have the ability to use critical thinking skills to evaluate the significance of identified discrepancies and be able to effectively communicate with providers and others to affect change and ensure coding and documentation compliance. To perform most effectively, the Auditor must remain current on CPT-4/HCPCS and ICD-10-CM coding guidelines, AHA coding clinics, and risk adjustment reimbursement reporting requirements and changes to the CMS-HCC model, as well as current government oversight and enforcement activities around risk adjustment.
Essential Functions
- Audit Planning: Develops coding and documentation audit plans for annual and periodic audits and investigations, using knowledge of key risk areas in coding and documentation compliance.
- Conducting Audits: Performs coding and documentation audits, reviewing medical records and charges to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines and standards, as well as the Centers for Medicare & Medicaid Services (CMS) coverage guidelines.
- Investigations and Monitoring: Tracks and maintains monitoring program to identify potential coding and documentation issues, conduct investigations as needed, and escalates significant findings/trends to the Director of Auditing and Monitoring.
- Analysis, Reporting, and Education: Conducts analysis of audit findings to identify trends/problems in coding and documentation and effectively leads educational meetings with providers to review the audit findings and recommend areas for improvement.
- Compliance Program Activities: Participates in compliance program activities, such as assisting with policies and procedures related to billing and coding compliance, risk assessment and compliance workplan development, and presents updates to Executive Compliance Committee.
- Other responsibilities include:
- Serves as a subject matter expert on interpretation and application of coding and documentation guidelines.
- Recommends procedural or policy changes to improve coding and documentation practices based on industry knowledge and audit findings.
- Monitors relevant resources, publications, and current government compliance and enforcement activity related to high-risk compliance areas.
- Stays current on coding guidelines, risk adjustment reimbursement requirements, and changes to the CMS-HCC model.
- Performs related work and projects as required.
- Complies with HIPAA laws and regulations and all applicable company rules and policies.
Qualifications
- Associate degree in healthcare administration, a related degree, or equivalent experience.
- Minimum of 5 years of risk adjustment coding experience as an Auditor/coder within a health plan or medical group/physician office setting.
- Minimum of 5 years of medical coding experience (CPT-4/HCPCS and ICD-10-CM) in a medical group/physician office setting.
- Active certification in medical coding (CPC or CCS-P) through AAPC or AHIMA, as well as active certification as a risk adjustment coder (CRC) through AAPC.
- Preference will be given to candidates who are certified in medical auditing, certified in healthcare compliance, and/or current or former licensed clinicians (e.g., RN).
- Comprehensive knowledge of Medicare rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation.
- Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements, including Physician, Multi-Specialty, Surgical, Hospital, Lab, Pharmacy, or other related Code Sets, with ability to research coding related questions.
- Required skills include:
- Demonstrated ability to:
- identify issues in coding and documentation practices and develop plans to remediate.
- develop reports, track, and trend audit findings and results.
- interpret national coding and documentation guidelines and translate them into effective auditing practices and tools.
- make timely and appropriate judgements on audit findings and translate into needed actions and follow up plans.
- effectively communicate with providers regarding coding and documentation improvement
- Excellent verbal/written communication skills.
- Excellent time management, attention to detail, follow up skills, organizational skills, and ability to prioritize work and meet deadlines.
- Proficient user in MS office suite: Excel, Outlook, PowerPoint, Word.
Benefits
- Competitive pay
- A friendly and fast-paced environment working with passionate people
- Medical, vision, dental and life insurance
- Short and long-term disability
- PTO and paid holidays
- Comprehensive benefits package
- 401k plan with match
