Internal Auditor - In/Outpatient

Summary/Objective
Under the supervision of the Manager, Compliance and Quality Audit, Omega Internal Auditor will perform reviews of inpatient and outpatient medical records for coding accuracy and medical record documentation as it impacts the accuracy of ICD-10-CM, ICD-10-PCS codes driving the MS-DRG/APR-DRG assignment and ICD-10 CM and CPT-4/HCPCS codes driving the APC assignment. The Auditor must also be able to identify coding trends, physician query opportunities, assess the accuracy of POA, discharge disposition and modifier assignments. Utilizing audit software tools or manual Excel templates to perform data collection for quality and statistical purposes for reporting and education to the Coder, Client, and Omega management. 

                                                                                                                              

Essential Job Functions

• Review inpatient and outpatient medical records for accuracy of coding and data quality. Elements to be included in reviews can include:

Inpatient Cases

• All diagnosis and procedures assigned ICD-10-CM and ICD- 10 PCS codes
• Validation of MS-DRG/APR-DRG
• APR, SOI, and ROM assignment
• Query opportunities
• Discharge disposition assigned
• Assigned Present on Admission (POA) indicators 

     Outpatient Cases (ER, SDS, Observation, Ancillary)

• All diagnosis and procedures assigned ICD-10-CM and ICD-10 PCS codes
• All CPT assigned codes
• APC assignment
• Modifier use and assignment
• E/M facility level codes (if required)
• Infusions and injections (if required)
• Maintain auditing productivity based on Client and Omega agreed upon requirements.
• Complete Quality Review reports timely and submits to coder, Omega management (subsequently to Client) for review.
• Utilize all available official coding references to perform reviews, to include but not limited to International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM and ICD-10-PCS), the Current Procedural Terminology (CPT-4) Official Coding Guidelines, Coding Clinic, CPT Assistant, CMS guidelines, etc.
• Utilize client specific coding policies and guidelines in conjunction with Official Guidelines to perform reviews.
• Communicate effectively with supporting staff and Omega point-of-contact(s).
• Provide information regarding work progress, actions, and issues in a timely and effective manner.
• Must be skilled in Microsoft Excel.
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

 

Key Success Indicators/Attributes

• Extensive knowledge of ICD-10-CM, ICD -10 PCS and CPT-4 coding and MS-DRG and APR-DRG assignment.
• Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing in addition to those that are state-specific.
• Knowledge of coding conventions and rules established by the American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes.
• Knowledge of JCAHO, coding compliance and HIPAA-HITECH standards affecting medical records and the impact on reimbursement and accreditation.
• Knowledge of documentation requirements to support coding and POA assignment is required.
• Extensive knowledge of medical terminology, anatomy, and physiology.
• Ability to prioritize and multi-task in a multifaceted environment.
• Demonstrate strong organizational skills and detail oriented.
• Demonstrate ability to self-motivate, set goals, and meet deadlines.
• Demonstrate professional demeanor and strong interpersonal skills.
• Demonstrate excellent presentation, verbal, and written communication skills.
• Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
• Maintains courteous and professional working relationships with employees at all levels of the organization.
• Demonstrate excellent analytical, critic