Medical Coding Quality Auditor- Hospital Outpatient at Guidehouse
Remote – Medical Coding Quality Auditor- Hospital Outpatient
- Virtual, United States
- Client Services
Guidehouse is a leading global provider of consulting services to the public sector and commercial markets, with broad capabilities in management, technology, and risk consulting. By combining our public and private sector expertise, we help clients address their most complex challenges and navigate significant regulatory pressures focusing on transformational change, business resiliency, and technology-driven innovation. Across a range of advisory, consulting, outsourcing, and digital services, we create scalable, innovative solutions that help our clients outwit complexity and position them for future growth and success. The company has more than 12,000 professionals in over 50 locations globally. Guidehouse is a Veritas Capital portfolio company, led by seasoned professionals with proven and diverse expertise in traditional and emerging technologies, markets, and agenda-setting issues driving national and global economies.
Internal Quality Reviewer – Outpatient shall report directly to the Internal Quality Control Director and will be responsible for accessing and reviewing the medical record documentation, coding and abstracting accuracy as defined in quality review policies and facility guidelines utilizing ICD-10 CM/PCS and CPT coding classification systems. Review of patient records will be conducted via facility EMR, scanning technology or other established method. All reviews will be entered daily into Guidehouse proprietary quality review tracking and trending software and will respond to coder rebuttals in a timely manner (timeline defined in quality review policies and procedures). This position will perform any and all related job duties as assigned.
Essential Job Functions
- Strong computer knowledge (well versed in excel and word)
- Excellent verbal and written communication skills
- Meet review productivity and quality standards
- Maintain HIPAA compliant workstations, strong knowledge of protected health information guidelines.
- Advanced Coding Skills, ICD-10-CM/PCS and CPT
- Strong knowledge of official coding guidelines as well as associated government regulations
- Ability to work independently and multi-task
Duties and Responsibilities
- Quality reviewer will be responsible for reviewing the entire patient record documentation for the date of service being audited to validate all code and abstracting data elements.
- Validation of the applicable code elements i.e. DRG, diagnosis, procedure, modifier and/or Evaluation and Management code level assignments are based on the following: supporting patient record documentation, Official Coding Guidelines (ICD-10 CM/PCS and CPT), Coding Clinics, CPT Assistant and any other federal coding guidance or regulation. All codes assigned should be supported by chart documentation and clinical evidence and/or treatment and monitoring.
- Ensure 3-5% coding quality review (or percentage stipulated in client contract) of each coder’s work is conducted monthly for facilities the reviewer is assigned.
- Coding quality review will be conducted to identify abstracting (to include dc disposition and POA indicators), ICD-10-CM, ICD-10-PCS, CPT, modifier, and HCPCS coding errors for codes assigned by the coding team (see quality review policies for review details).
- Reviewer will run coder productivity reports (where applicable) to pull random sample accounts for review and to ensure review numbers or percentages are met
- Review coding and abstracting (as defined by the facility) on patient types assigned to review: inpatient, ambulatory surgery, observation, emergency room with or without E/M levels, clinic, ancillary, diagnostics, etc to assure 95% coder accuracy (or as stipulated by client contract).
- Become familiar with any facility specific coding guidelines and know where to access on the Guidehouse portal.
- Required to read all Coding Clinics and CPT Assistant updates published by the education team and stay abreast of all new coding guidelines.
- Ensure code recommendations entered into GuideAudit are supported by quoting AHA official Coding guidelines, Coding Clinics, CPT Assistant and/or other official coding references. Reviewers shall also document the specific record documentation that supports any code recommendation.
- Notifies each coder when monthly review has been completed and respond to coder rebuttals in timely manner (see quality policy and procedures for required timeline requirements)
- Enter review findings daily into quality software daily OR at a minimum within 24 hours of review (exception is pre bill accounts which MUST be entered same day received and reviewed)
- Conduct coder pre bill reviews as priority and complete the review and corresponding data entry into GuideAudit same day received
- Communicate (via email) coder quality pre bill score to coder, coding managers (onshore and offshore), Coding Director, IQC Director and/or Pro Fee Supervisor and VP Quality
- Communicate in a professional, educational, non-threatening mentorship manner with the coding team in coding quality recommendations and rebuttal discussions.
- Follows review escalation policy when coder/review disagreements occur (see quality review policy/procedures).
- Notify Director and VP of Quality when coders fall below accuracy standard, coding risk areas and error trends are identified for a specific facility and/or coder.
- Assist Coders in answering coding/abstracting questions resulting from quality reviews.
- Will conduct coder intensification reviews for Coders who fall below the stipulated accuracy rate as part of the corrective action plan (per guidance of Review Lead or IQC Director)
- Maintain working knowledge of ICD-10-CM/PCS and CPT coding principles, government regulations, official coding guidelines, and third party requirements regarding documentation and billing.
- Ability to maintain review productivity standards as follows:
- Inpatients 1.5 – 2 charts per/hour
- Outpatient surgery – 3 charts per/hour
- Emergency room/clinics – 11 charts per/hour
- Emergency room with Evaluation & Management leveling – 7-8 charts per/hour
- Ancillary/diagnostic – 15 charts per/hr.
** This excludes outliers (i.e. long length of stay, voluminous or very complex records etc) which will be captured on activity review summary
- Complete review activity summary daily (productivity summary) for each facility and submit to IQC Director, Professional Fee Supervisor and VP of Quality on a weekly basis (utilized in calculation of quality review FTEs and productivity).
- Assist as needed in the review of external coding audit company findings and assist in in formulating a response as requested
- Participate in client conference calls and mandatory monthly quality team stand-up calls. Responsible to review the minutes of monthly quality stand up calls if not able to dial into the conference call (minutes are posted on the portal).
- Provide company support for the creation, maintenance and ongoing operation of an efficient and accurate Quality Improvement Plan that is compliant with Local, State, and Federal Government Regulations.
- Work with the Coding Solutions Division to provide on-going coding education resulting from the Quality Reviews when requested
- Maintain open lines of communication serving as a liaison between client, Coders, and Coding Solutions Division to ensure that all parties are kept up to date on specific hospital guidelines/policies.
- Participate in company Coding Solutions Division Meetings as requested.
- Reviewer must be able to work independently while maintaining productivity standards.
- Advanced computer skills are required to handle connection issues, downloads and to review specific programs.
- Reviewer downtime due to connectivity issues (client system, GuideAudit or other) must be reported immediately to the IQC Director and/or Pro Fee Supervisor immediately to ensure appropriate actions taken to resolve to ensure minimal downtime and interruption to work flow/productivity.
- Facility access/connectivity problems should be reported to onshore Guidehouse Coding Manager for the facility, IQC Director and/or Pro Fee Supervisor to provide direction about next steps to resolve the issue as soon as possible.
- Reviewers are responsible for checking and responding to Guidehouse email system at the beginning of their shift, at least every two hours during working hours AND at the end of their shift. These same requirements apply to the client secure email system.
- Reviewers are responsible for maintaining HIPAA compliant workstations (reference HIPAA work station policy).
- Reviewers are responsible for maintaining patient privacy at all times (reference company handbook policy).
- Reviewers are responsible for signing a confidentiality statement.
- It is the responsibility of each reviewer to review and adhere to the coding division coding policy and procedures on the Guidehouse portal.
- Works well with other members of the facility coding and billing team to insure maximum efficiency and accurate reimbursement for documented services.
- Communication in emails should be professional and collaborative at all times (reference e-mail p
Education /Qualifications /Experience
- Must hold one of the following credentials: (RHIT, RHIA, CCS, CPC, CIC or COC).
- Must maintain coding credential while employed by Guidehouse.
- Must pass Guidehouse coding competency exam.
- Must have three years of coding or review experience for the type of work being assigned.
- Abide by all client policies and procedures.
- Abide by all Guidehouse policies and procedures.
- Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service.
Experience in the following areas:
- Outpatient Facility Coding
- Facility ED and E&M leveling
- Injection and Infusion
- The successful candidate must not be subject to employment restrictions from a former employer (such as a non-compete) that would prevent the candidate from performing the job responsibilities as described.The salary range for this role is $38.00 – $40.00 , may vary based on experience and location.
Guidehouse is an Equal Employment Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, citizenship status, military status, protected veteran status, religion, creed, physical or mental disability, medical condition, marital status, sex, sexual orientation, gender, gender identity or expression, age, genetic information, or any other basis protected by law, ordinance, or regulation.
Guidehouse will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of applicable law or ordinance including the Fair Chance Ordinance of Los Angeles and San Francisco.
If you have visited our website for information about employment opportunities, or to apply for a position, and you require an accommodation, please contact Guidehouse Recruiting at 1-571-633-1711 or via email at RecruitingAccommodation@guidehouse.com. All information you provide will be kept confidential and will be used only to the extent required to provide needed reasonable accommodation.
Guidehouse does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Guidehouse and Guidehouse will not be obligated to pay a placement fee.
Rewards and Benefits
Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid Holidays
- Position may be eligible for a discretionary variable incentive bonus
- Parental Leave and Adoption Assistance
- 401(k) Retirement Plan
- Basic Life & Supplemental Life
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach
- Emergency Back-Up Childcare Program