General Information
| Job Description | AUDIT PROFL 3 | Working Title | Physician Documentation and Coding Auditor |
|---|---|---|---|
| Job Code | 007575 | Grade | 22 |
| Department Name | SOM Compliance Dept - D02010 | Department Head | Paul Hackman |
| Supervisor | Christine Davis | Effective Date | 10/01/2023 |
Position(s) Directly Supervised
| Job Code | Title | FTE |
|---|
Generic Scope
| Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems/issues of diverse scope and determines solutions. |
Custom Scope
| Performs the full scope of auditing encompassing financial, compliance, information systems, and effectiveness reviews according to professional auditing standards. Normally receives general instructions on routine audit work with detailed instruction on new or more complex audit assignments. May provide functional advice, training and/or guidance to less-experienced audit professionals. |
Department Custom Scope
| The Physician Documentation and Coding Auditor will contribute to our growth and success in meeting our mission by reviewing, analyzing and assuring that the documentation of final diagnoses and procedures as stated by the practicing providers are valid and complete. Will perform regular compliance audits to identify and correct any incorrect coding and related billing errors. Will collect data to establish trends by diagnoses code, physician, or procedures to ensure proper reimbursement and educate providers on best practices to reduce denials from payors. The current setting for this position is hybrid with in-office setting three days per week with a remote option two days/week. Position is located at the UC Intelli-Center: 14350 Meridian Parkway, Riverside, CA, with planned re-location to the UCR Campus in Fall, 2023. Campus address: 900 University Ave Riverside, CA 92521. |
Education & Experience Requirements
Education Requirements
| Degree | Requirement |
|---|---|
| Bachelor's degree in related area and/or equivalent experience/training. | Required |
Experience Requirements
| Experience | Requirement |
|---|---|
| 4 - 7 years of related experience. | Required |
| Experience using MD Audit | Preferred |
| Experience with research/clinical trials billing and coding | Preferred |
| Demonstrated experience of performing analysis and providing solutions to complex problems; developed recommendations independently for process improvements for health systems operations. | Preferred |
| Experience with University of California policies, procedures, forms, organization and structure | Preferred |
| Experience utilizing an electronic auditing software and ability to audit from electronic health records. | Required |
| Four years of experience must be in coding of professional services including assignment of E/M levels, CPT codes and ICD diagnosis codes is required. At least one of these years must be conducting coding and billing audits. | Required |
License Requirements
Certification Requirements
| Certification | Requirement |
|---|---|
| Current certification as a Professional Coder from the AAPC; ability to provide current documentation from appropriate agency. Maintain professional certification education requirements to enhance personal growth. | Required |
Educational Condition Requirements
| Condition | Requirement |
|---|---|
| A minimum total of eight years of experience can substitute for the degree requirement. | Required |
Key Responsibilities
| Description | % Time |
|---|---|
| Education and Training: Provides regular compliance training on coding and reimbursement matters and as necessary provides training based on the findings of compliance reviews. Performs routine and focused educational programs in compliant coding and related regulatory updates. Develops educational materials, and presents educational information to the providers, and assists other areas by providing staff training to enhance proficient documentation and coding. Provides compliance education and training to physicians, residents, fellows, nurse practitioners, physician assistants and other appropriate personnel for both scheduled and ad hoc requests. Provides direct training in support of continued adherence to policies and procedures for teaching physician billing compliance and associated policies and procedures. Participates in evaluating and updating of educational and training materials related to billing, coding, and documentation practices and other compliance obligations as needed. Participates in onboarding of new clinical faculty. | 30 |
Independently performs audit projects at all levels of complexity. Involves preliminary survey and risk assessment activities. Under guidance, designs audit programs to accomplish review objectives.
|
20 |
Conducts testing based on approved audit programs of moderate to high complexity, which may include tests of the financial and operating system processes, to identify internal control weaknesses and audit findings.
|
20 |
Develops formal written reports to communicate audit results to campus management, and makes recommendations as appropriate.
|
10 |
| May participate in investigations and assist with evaluation of allegations, including improper government acts. Follows up on management corrective actions to ensure completion. | 5 |
| May be responsible for external audit liaison duties: coordinates external agency information requests and site visits; analyzes documentation to identify potential risk areas. | 5 |
| Administrative and Meetings: Independently prepares and edits materials for various projects, including electronic presentations, reports, correspondence and data collection. Maintains a current, organized and detailed audit file system. Responds to incoming phone calls, emails and texts from approved platform from coders, billers, and physicians, supervisor and others in a timely manner. Participates and provide regular reports in various committees. | 5 |
| Physician coding: Abstracts information from various chart documentation, dictated reports, electronic health records, encounter forms, hand-written progress notes and various other venues with the use of audit tools to reach appropriate CPT/ASA procedure codes, E/M (Evaluation & Management) codes and all other appropriate billing codes in compliance with University policies and government billing policies. Takes appropriate action if documentation does not support codes. Analyzes and evaluates findings, diagnosis & procedure codes identified by physicians. Reports inconsistencies and/or incomplete charts, to inform the department and/or provider to improve billing/coding practices. Uses sound coding judgment to establish priority sequencing of diagnosis codes & services for maximum allowable reimbursement, consistent with but not limited to University compliance regulations, CMS Medicare & Medi-Cal, HMO, commercial insurance carriers and other related entities; confirms that all codes/modifiers are appropriate. Interacts with internal and external resources to facilitate all aspects of medical coding. Supports Chief Compliance Officer with coordinating and facilitating periodic third party audits. | 5 |
Knowledge, Skills & Abilities
| Knowledge/Skill/Ability | Requirement |
|---|---|
| Thorough knowledge of the audit profession, theories and systems of internal control, and professional auditing standards. | Required |
| Organizational skills to prioritize workload and meet deadlines; develop and carry out project assignment in an efficient and timely manner. | Required |
| May require specialized expertise in enterprise software and relational databases. | Required |
| Demonstrated skill working with computerized reports to abstract information. | Required |
| Gathers, organizes and performs analysis for moderately complex audit assignments. Is working on mastering more advanced audit concepts and applications in the completion of assignments. | Required |
| Strong interpersonal and communication skills to present sensitive information with diplomacy and in a clear and concise manner. Presents to a wide variety of audiences, including senior management and external agencies. | Required |
| Comprehensive knowledge of medical diagnostic and procedural terminology. | Required |
| Working knowledge of Microsoft software applications. | Required |
| Ability to maintain work focus with changing priorities, frequent interruptions and stressful situations. | Required |
| Demonstrated knowledge and understanding of the seven essential elements of an effective compliance program. | Required |
| Ability to input, work with, and manage data and detail with a very high degree of accuracy and with measures to ensure quality of the product. | Required |
| Demonstrated knowledge and understanding of federal and state statues, laws, rules and regulations related to billing, coding, and documentation practices in support of healthcare services provided to beneficiaries of federally funded healthcare programs and other third party payers. | Required |
| Broad knowledge of finance, accounting, business and systems operations. | Preferred |
Special Requirements & Conditions
| Special Condition | Requirement |
|---|---|
| Must pass a background check. | Required |
| Travel | Required |
| Travel Outside of Normal Business Hours | Required |
Other Special Requirements & Conditions
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Level of Supervision Received
| General Supervision |
Environment
Working Environment
| Hybrid: 3 days in office w/remote option 2 days/week. Located at 14350 Meridian Pkwy, Riverside. |
Other Requirements
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Physical Requirements
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Mental Requirements
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Environmental Requirements
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Critical Position
| Is Critical Position: Yes |