Overview of Role

The Senior Outpatient and Professional (OP/PF) Coding Auditor is a seasoned leader on the Penstock Audit team, responsible for ensuring that outpatient and professional services are coded and billed in accordance with applicable policies, guidelines, and regulations. The Senior OP/PF Auditor embodies the standards of honesty, excellence, and innovation that are central to the Penstock mission, and serves as a resource and mentor for other Audit Team members.

• Conducts thorough, thoughtful reviews of healthcare claims and medical records to identify inappropriate payments and improper billing practices

• Identifies and refers scenarios that require input from a clinical auditor

• Writes thorough, accurate, and well-documented rationale to support audit determinations, citing appropriate guidelines, policies, regulations, and/or CPT Assistant advice

• Prepares written responses and/or participates in conference calls regarding payor or provider questions about Penstock audit findings

• Supports the ongoing Penstock mission of improving healthcare reimbursement by highlighting possible provider training needs and helping prepare and/or conduct education sessions on potentially sensitive topics

• Helps analyze audit results to identify opportunities for edit refinement and/or internal training

• Keeps abreast of coding, clinical, regulatory, and other industry changes that impact Penstock auditing and/or that suggest new audit opportunities

• Participates in keeping the OP/PF Audit team informed of industry changes that impact auditing

• Maintains focus on the identification and development of new audit concepts

• Continuously considers the systems and processes involved with healthcare reimbursement (both internal and external) and communicates ideas for improvement through appropriate channels

• Communicates kindly, professionally, and effectively with all customers, both internal and external, and refers issues to management as appropriate

• Continuously strives to find new avenues for fulfilling the Penstock mission of reclaiming greater integrity between payors and providers

• Serves as a Payment Integrity subject matter expert for Penstock team members and for the Goodroot organization as a whole

• Meets or exceeds Penstock’s performance and quality standards.

Qualifications and Education Requirements

• Minimum of an associate degree

• Current AAPC or AHIMA coding credential

• Comprehensive understanding of CPT coding rules and conventions

• 5 or more years of CPT coding experience in a healthcare facility setting or large professional practice

• Recent experience auditing health insurance claims for improper payments

• Familiarity with government and commercial billing rules and payment methods

• Awareness of and adherence to HIPAA, and all laws regarding the safeguarding of PHI/PII

• Ability to conduct independent research using credible sources

• Demonstrated working knowledge of Microsoft Word, Excel, and PowerPoint

• Ability to apply critical thinking skills to record reviews

• Ability to work independently, manage workload, and adapt to shifting priorities

• Excellent communication skills, both oral and written

• Comfortable working in an ever-changing environment

• Able to work Eastern time zone hours

• Secure and private home office with reliable high-speed internet connection

Preferred Skills

• Bachelor’s degree

• 7+ years of relevant auditing and/or coding experience with a mastery of skills in at least one specialty area, such as Interventional Radiology, Orthopedic Surgery, Ophthalmology, Cardiology and/or Spine Surgery with the ability to mentor other team members.