Quality Auditor

JD -Quality Auditor

Job Title- Certified Auditor

Schedule: 8am to 5 pm EST

The Outpatient Coding Auditor is responsible for conducting detailed reviews of coded outpatient medical records to ensure coding accuracy, documentation compliance, and regulatory alignment. This includes validating CPT/HCPCS and ICD-10-CM codes assigned for emergency room, same-day surgery, observation, ancillary services, and outpatient clinic visits. The role ensures the hospital's outpatient coding practices are accurate, compliant, and aligned with payer rules and coding guidelines, ultimately supporting the revenue integrity of SRMC.

Key Responsibilities:

Coding Audit and Validation

* Review a sample of coded outpatient records including:

o Emergency Department (ED)

o Outpatient Surgery (Day Surgery)

o Observation cases

o Radiology and Laboratory services

o Outpatient Clinic encounters

* Validate CPT, HCPCS, and ICD-10-CM codes for diagnoses, procedures, and E/M levels.

* Ensure accuracy in modifier usage, code selection, and code sequencing.

* Confirm services are supported by clinical documentation and aligned with CMS Outpatient Prospective Payment System (OPPS) rules, NCCI edits, and payer policies.

* Identify coding errors including overcoding, undercoding, and missed codes, incorrect sequencing, and incorrect modifiers.

Documentation Review & Query Support

* Assess documentation for clarity, completeness, and compliance with coding requirements.

* Provide feedback to coders regarding missed opportunities or documentation improvement needs.

Compliance & Regulatory Oversight

* Ensure coding practices follow:

o AHA CPT Guidelines

o ICD-10-CM Official Guidelines for Coding and Reporting

o NCCI (National Correct Coding Initiative) edits

o Medicare/Medicaid and commercial payer rules

* Identify and escalate potential compliance risks including unbundling, modifier misuse, and billing conflicts.

Reporting & Education

* Prepare detailed audit findings reports summarizing results, trends, and recommendations.

* Deliver targeted education and training to outpatient coding staff based on audit findings.

* Track individual coder and team performance, providing ongoing coaching and resources.

* Collaborate with coding supervisors, trainers, and HIM leadership to implement corrective actions.

Qualifications:

* Required Certifications:

o CPC, CCS (AHIMA or AAPC credential required)

* Experience:

o 3+ years of hands-on outpatient coding experience in a U.S. hospital setting

o Prior experience with coding audits or quality assurance highly preferred

* Strong knowledge of:

o CPT, HCPCS, ICD-10-CM

o Modifier usage (e.g., -25, -59, -LT/RT, etc.)

o Outpatient reimbursement methodologies (e.g., APCs, OPPS)

o CCI edits and MUEs

* Familiarity with encoder software and EHR platforms (e.g., 3M, Epic, Cerner, TruCode)

* Strong analytical and communication skills

Performance Metrics:

* Audit Accuracy Standard: 95%

* Timeliness: Audit completion within defined SLA)

* Reporting: Timely delivery of audit summaries and feedback reports

* Education: Contribute to team training or knowledge sharing on a regular basis.

We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.