Key Responsibilities:
Review and audit medical records to ensure accurate and compliant clinical documentation and coding.
Verify that diagnoses, procedures, and services are correctly coded according to ICD, CPT, and other relevant standards.
Identify and address discrepancies or errors in coding and documentation.
Provide feedback and training to coding staff and healthcare providers to improve coding accuracy and compliance.
Ensure adherence to hospital policies, regulatory requirements, and coding guidelines.
Prepare audit reports highlighting findings, trends, and recommendations for process improvements.
Collaborate with the coding and billing teams to resolve issues and enhance overall revenue cycle efficiency.
Keep updated with changes in coding standards, healthcare regulations, and compliance requirements.
Requirements:
Certification in Medical Coding (e.g., CPC, CCS, or equivalent).
Proven experience in clinical coding, auditing, or a related role within a healthcare setting.
Strong knowledge of ICD, CPT, HCPCS, and other coding systems.
Familiarity with medical record documentation standards and healthcare compliance regulations.
Excellent attention to detail and analytical skills.
Good communication skills and ability to provide constructive feedback.
Ability to work independently and as part of a team.