Capstone Performance Systems, a subsidiary or Tabula Rasa Healthcare is seeking a Remote Clinical Auditor who reviews, analyzes, and codes documentation from medical records that determines payments. This position performs highly technical and specialized functions, and the primary function of this position is to perform a thorough review of patient encounters to assess for completeness and accuracy of provider documentation and ICD-10-CM, CPT and HCPCS coding. The auditing function is a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines. Secondary function of this position is to provide coordination and oversight of non-PACE accounts.
- Performs clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding based on CMS Hierarchical Condition Categories (HCC) conditions that are applicable to Medicare Risk Adjustment reimbursement initiatives
- Integrates coding principles in performance of medical audit activity and educates as needed on those principles
- Upon completion of medical record audit, compiles detailed findings and prepares client reports, when needed.
- Performs reviews for prospective audits, retrospective audits, and RADV and/or other regulatory audits when requested by Client.
- Oversees auditing work ensuring accordance with departmental auditing standards and staffing matrix
- Coordinates with client to ensure patient data is received and processed for all scheduled audit work
- Communicate proper volume to support invoicing.
- Ensures all parties adherence to contract obligations are met
- Provides feedback and process improvement recommendations to appropriate leadership team and participates in workgroups/committee meetings and process improvement solutions as required.
- Coordinates with Consulting team
- Advises Consulting team of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
- Maintains professional license and certifications and attends training conferences/webinars as necessary to keep abreast of latest trends in the field of expertise.
- Performs other functions as required.
Other Duties and Responsibilities:
• Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and
changes in the laws and regulations governing medical ICD-10 CM coding and documentation.
• Understands and adheres to The Health Insurance Portability and Accountability Act (HIPPA) requirements
• Participates as requested in department meetings, client calls, and annual performance evaluation
• Performs other duties and responsibilities as required
• Completes miscellaneous projects for Capstone as assigned or requested.
Education and Certifications:
Associate Degree equivalent or graduate of accredited practical nursing program which may be either college or community vocational/technical school based required.
Valid nursing license (RN/LPN) required and:
Certified Registered Nurse coder (CRN-C), Certified Coding Specialist designation (CCS) issued by the
American Health Information Management Association; or, Certified Professional Coder (CPC)
Registered Health Information Administrator (RHIA), or Registered Health Information Technologist (RHIT) with 6 months experience coding ICD-10 CM.
• Certified Risk Adjustment Coder (CRC) or equivalent
Experience and Training:
- Documentation Improvement experience
- Experience in Hierarchical Condition Categories (HCC)
- Knowledge of or experience in Medicare Advantage plans
- Knowledge of or experience in managed health care systems, PACE or Medicare.
- Experience with MS Word, Excel, PowerPoint, and comfortable with learning and becoming an expert on new and proprietary software.
- Highly skilled in written and verbal communication.
- Highly skilled at establishing priorities and coordinating work activities.
- Skilled at performing multiple and complex tasks.
- Establishes and maintains effective working relationships with clients
- Has exceptional initiative and follow-through on projects with minimal supervision or guidance.
- Must be detail oriented, follow instructions and work independently with minimal supervision with highly confidential information per HIPAA regulations.