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Senior Outpatient and Professional Coding Auditor
Senior Outpatient and Professional Coding Auditor

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.

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