Lead Compliance & Quality Audit

Summary/Objective
Under limited supervision, Omega’s Lead Compliance and Quality Audit Manager performs audits 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 assignment and ICD - 10 CM and CPT-4/HCPCS codes driving the APC assignment. Lead Compliance and Quality Audit Manager must be able to identify Physician query opportunities, assess the accuracy of POA, discharge disposition and modifier assignments. Lead Compliance and Quality Audit Manager performs data collection for quality and statistical purposes and reports the finding the Client. The Lead Compliance and Quality Audit Manager is the first line of support for the HIM QA Managers, assists in coaching and developing staff members as necessary and completes special projects as assigned. 

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/Observation Cases

  • All diagnosis and procedure assigned ICD-10-CM and ICD- 10 PCS codes

  • Discharge disposition assigned

  • Assigned Present on Admission (POA) indicators 

  • APR, SOI, and ROM assignment for inpatient cases

  • All diagnosis and procedure assigned ICD-10-CM and ICD-10 PCS codes

  • All CPT assigned codes

  • Modifier use and assignment

  • APC assignment

  Outpatient Cases (ER, SDS, Ancillary)

Professional Services

• All diagnosis codes

• All CPT assigned codes

• All E&M leveling codes

• Maintain auditing productivity based on Client and Omega agreed upon requirements. 

• Complete Quality Review reports timely and submits Omega (subsequently to Client) for review.

• Work with the Omega Compliance Team to develop and provide coder/coding training and education sessions, group, or one-on-one sessions, as needed, based on results of the Coding Quality Reviews.

• Provide support in the absence of the Manager, CQA Services, demonstrating aptitude to temporarily perform all duties of the Manager, CQA Services.

• Provide support for special assignments which may include but are not limited to phone assessments, CodeONe, strategic initiatives and cross functional teams.

• Utilize all available official references to perform reviews: to include but not limited to International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the Current Procedural Terminology (CPT-4) Official Coding Guidelines, Coding Clinic, CPT Assistant, CMS guidelines, etc. 

• Communicate effectively with supporting staff and Omega point-of-contact(s). Provides 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 documentat