Conduct pre-bill high-risk audits across inpatient and/or outpatient encounters, targeting complex, high-acuity, high-impact cases.
Perform advanced DRG validation, including MCC/CC integrity and clinical documentation alignment on inpatient audits.
Review and validate appropriate application of ICD-10-CM/PCS or CPT/HCPCS and modifier usage, as well as DRG/IPPS and/or OPPS/APC methodologies.
Partner with CDI, physicians, and coding teams to resolve complex documentation and coding scenarios prior to billing.
Collaborate with CDI on retrospective reviews to identify documentation and coding opportunities and improve accuracy.
Support CloudMed DRG validation reviews and/or charge capture reviews to ensure accurate representation of patient acuity and appropriate reimbursement.
Participate in coding and CDI escalation reviews, providing expert validation on complex cases.
Identify and escalate coding, regulatory, and denial risk trends to support enterprise risk mitigation strategies.
Provide detailed audit findings and support development of targeted education based on high-risk audit results and regulatory updates.
Track and report on audit outcomes, risk exposure, and resolution of high-risk coding issues.
Perform RAC and Commercial post-payment audit rebuttals and outpatient denials.
Perform other duties as assigned.
Proficient experience with EMR and CAC systems, with Epic and Optum preferred.
Advanced knowledge of ICD-10-CM/PCS or CPT/HCPCS coding, DRG/IPPS methodology, and/or APC/OPPS methodology.
Strong understanding of clinical documentation and acuity presentation.
Ability to interpret and apply regulatory guidance, including CMS, OIG, NCCI, OPPS, and IPPS.
Ability to identify and mitigate coding and compliance risks.
Strong analytical and problem-solving skills.
Ability to translate audit findings into clear, actionable feedback and targeted education.
Effective communication and cross-functional collaboration skills.
Time management skills with the ability to work under pressure and meet deadlines.
Proficiency in Microsoft 365 office products.
Associate degree required; bachelor's degree preferred.
Healthcare-related field of study preferred.
6+ years of acute care inpatient or outpatient hospital coding required.
4+ years of auditing experience required.
Equivalent combinations of education and experience may be considered.
Required certification: CCS, RHIA, RHIT, CPC, or CIRCC.
Medical, dental, and vision insurance.
Life insurance and disability insurance.
Paid time off from day one.
403(b) retirement plan.
4 weeks of 100% paid parental leave.
Career development opportunities.
Whole person well-being resources.
Mental health resources and support.
Pet benefits.
Location
Florida, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$66,830 - $124,301
Remote work allowed
No
Posted
3 weeks ago