Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events for all lines of business
Coordinates rate adjustments with claims areas
Provides monthly and quarterly reports outlining trends
Serves as a resource in resolving coding issues
Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department
Determines methodology to identify cases for validation review
Conducts validation reviews/coordinates rates adjustments with appropriate claims area
Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates
Manages records retrieval, release, HIPAA compliance, and all aspects of document management
Serves as expert resource on methodology and procedures for medical records and coding issues

Associates in a job-related field
2 years job related work experience
3 years medical record management to include coding and validation review experience
Excellent verbal and written communication skills
Excellent organizational skills
Excellent customer service skills
Excellent analytical or critical thinking skills
Good judgment
Extensive medical records and coding knowledge
Working knowledge of contract evaluations, claims processing and adjudication practices
Registered health information administrator (RHIA) OR Registered health information technician (RHIT) OR Certified Professional Coder (CPC) OR Certified Inpatient Coder (CIC) OR Certified Professional Medical Auditor (CPMA) OR, active, unrestricted RN licensure from the United States
active compact multi-state unrestricted RN license as defined by Nurse Licensure Compact (NLC)

Quality Medical Auditor

Key skills