Medical Review Coding QA Auditor (Outpatient)
Location:United States – Remote
Status:Regular Full Time
The Medical Review Coding QA Auditor (Outpatient) is responsible for conducting Quality Assurance (“QA”) reviews of medical review audit work completed by the medical review coding audit team members to ensure the accuracy of claim findings and applicable documentation for our clients. Communicates and supports the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools. Responsible for performing some audit activity and consistently achieves or exceeds productivity goals and quality standards. Serves as subject matter expert, provides supplemental escalation support, and may perform special project activity as needed.
- Performs limited volume of outpatient coding reviews on medical records to maintain subject matter expertise, and additionally as needed to support business needs.
- Conducts quality assurance reviews on medical review audit work completed by the medical review coding audit team members, maintaining productivity and quality standards as defined by department policy.
- Objectively and accurately documents quality review results in accordance with department quality policies and procedures, scoring and reporting all QA results in an approved QA tracking system and routes record appropriately within audit platform based upon how QA review resulted in concurrence with audit finding or identified corrections required.
- Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings.
- Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings
- Contributes to the continuous improvement feedback process and suggests or makes any edits, documentation, next steps, and reporting as may be necessary in accordance with department process and audit leadership direction.
- May support findings during the appeals process, if needed.
- May perform primary audit activity as assigned by management
- Monitors, tracks, and reports on all work conducted in accordance with QA process and management direction.
- May prepare QA reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights.
- Consults with internal resources as necessary.
- Become subject matter expert for assigned business segment(s).
- Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.
- Participates in and contributes to applicable department meetings.
- Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and policy/procedures training applicable for position.
- Proactively contributes to continuous improvement of activities and sets positive example
- Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.
- May support training material/tools and best practices development.
- May identify/make recommendations to management for supplemental team/concept type training.
- May support training activities for new audit staff or provide supplemental training for existing staff as needed.
- Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.
- Receives feedback and adjusts work priority as necessary.
- Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.
- Performs job duties with high level of professionalism and maintains confidentiality
- Perform other incidental and related duties as required and assigned to meet business needs.
*Note – All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Performant’s policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Required Skills and Knowledge:
- Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others.
- Must be able to manage multiple assignments effectively, create documentation outlining findings, QA review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.
- Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.
- Proficiency with MCS 1500/UB 04 forms
- Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations.
- Working knowledge of encoder
- Proven ability to review, analyze, and research coding issues
- Reimbursement policy and/or claims software analyst experience
- Familiarity with interpreting electronic medical records (EHR)
- Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billi ng.
- Independent, out-of-the-box thinker; Performs successfully against work given in the form of objectives and projects; leads by example.
- Understands processes, procedures, and workflow; and demonstrated ability to identify areas of opportunity
- Demonstrated ability to consistently apply sound judgment and good effective decision making.
- Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals.
- Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions.
- Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.
- Demonstrated ability to collaborate effectively in a variety of settings and topics.
- Excellent editing and proofreading skills.
- Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.
- Excellent time management and delivers results balancing multiple priorities.
- Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.
- Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.
- Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.
- Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
- Ability to create documentation outlining findings and/or documenting suggestions.
- Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings.
- Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.
- Ability to be flexible and thrive in a high pace environment with changing priorities.
- Adaptable to applying skills to diverse operational activities to support business needs.
- Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.
- Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.
- Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment
- Ability to obtain and maintain client required clearances, if applicable, as well as pass company regular background and/or drug screening.
- Ability to obtain and maintain client required clearancesas well as pass company regular background and/or drug screening.
- Completion of Teleworker Agreement upon hire, andadherence to the Agreement (and related policies and procedures) including, butnot limited to: able to navigate computer and phone systems as a user to workremote independently using on-line resources, must have high-speed internetconnectivity, appropriate workspace able to be compliant with HIPAA, safety& ergonomics, confidentiality, and dedicated work focus without distractionsduring work hours.
**NOTE: Must be able to meet requirements for andperform work assignments in accordance with Company policies and expectationson a home remote basis (and must meet Performant remote-worker requirements)until at which time staff may be notified and required to work from aPerformant office location on an ad-hoc or periodic basis.
- Basic office equipment required to perform remote workis provided by the company.
- Job is performed in a standard busy office environmentwith moderate noise level (or may be home-office setting subject to Companyapproval and Teleworker Agreement), sits at a desk during scheduled shift, usesoffice phone or headset provided by the Company for calls, making outboundcalls and answering inbound return calls using an office phone system; views acomputer monitor, types on a keyboard, and uses a mouse.
- Reads and comprehends information in electronic(computer) or paper form (written/printed).
- Sit/stand 8 or more hours per day; has the option tostand as needed while on calls; reach as needed to use office equipment.
- Consistently viewing a computer screen and typesfrequently, but not constantly, using a keyboard to update accounts.
- Consistently communicates on the phone as requiredprimarily within the department and company and may include client contacts orother third-party depending on assignment with account holders, may dialmanually when need or use dialer system; headset is also provided.
- Occasionally lift/carry/push/pull up to 10lbs.
Education and Experience:
- Current certification as a CPC, CPC-H, CPC-P, RHIA, RHIT, CCS, or CCS-P
- Not currently sanctioned or excluded from the Medicare program by OIG
- 3+ years of direct experience in medical chart review for all provider/claim types for outpatient
- 5+ years relevant auditing experience in a provider or payer environment demonstrating breadth and depth of knowledge/skills for the position. (less than 5 yrs. may be considered for internal candidates based upon demonstrated skills and results).
- Prior experience in role with responsibility for conducting primary audit, utilization or prior-authorization work, or quality review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.)
- Prior experience in payer edit development and/or reimbursement policy a plus.
- Prior experience working in remote setting preferred.
Performant is a Government contractor and subject tocompliance with client contractual and regulatory requirements, including butnot limited to, Drug Free Workplace, background requirements, and clearances(as applicable).
- Must submit to and pass pre-hire background check, aswell as additional checks throughout employment.
- Must be able to pass a criminal background check; mustnot have any felony convictions or specific misdemeanors, nor on state/federaldebarment or exclusion lists.
- Must submit to and pass drug screen pre-employment (andthroughout employment).
- Performant is a government contractor. Certain clientassignments for this position requires submission to and successful outcome ofadditional background and/or clearances throughout employment with the Company.
Employment VISA Sponsorship is not available for thisposition
Job Profile is subject to change at any time.
Performant Financial Corporation is an Equal OpportunityEmployer.
Performant Financial Corporation is committed tocreating a diverse environment and is proud to be an equal opportunityemployer. All qualified applicants will receive consideration for employmentwithout regard to race, color, national origin, ancestry, age, religion,gender, gender identity, sexual orientation, pregnancy, age, physical or mentaldisability, genetic characteristics, medical condition, marital status,citizenship status, military service status, political belief status, or anyother consideration made unlawful by law.
NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZEDAGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER5.