Quality Auditor

Job Family Summary:

Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for Outpatient, Emergency department and day surgery records. Verifies all codes and sequencing for claims according to (DOH &DHA) coding guidelines, CPT Assistant, and national and local coverage decisions.

Role Summary:

To audit claims coded by coders, perform TNA and provide efficient training and bridge the knowledge gap in coders.

Primary Responsibilities:

• Ensure that the medical ethics are respected at all times while performing the medical evaluation of the claims.
• Responsible for retrospective and concurrent reviews on coding staff.
• Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed.
• Review provider's specifications and highlight inconsistencies or lack of information. Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely and professional manner.
• Conduct training to improve the technical, insurance and medical skills and knowledge for team members as assigned by the QA lead.
• Participate and contribute during biweekly calibration on error grading standards to help build a robust Quality Program along with QA lead.
• Provide all the needed support as advised by the supervisor/Manager based on the business need.
• Responsible of successful Ramp up plan of new coders.
• Ensure the audit tracker is updated and the data provided is accurate.
• Suggestions to create audit tools and strategies to improve the audit process

Job Requirements:

• Bachelors Degree in the medical field or science background
• Coding certification from AAPC or AHIMA is mandatory.
• Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, HCPCS codes, modifiers, MUEs, CCI edits.
• Advanced knowledge and understanding of anatomy and physiology, medical terminology, pathophysiology (disease process, surgical terminology and pharmacology.)
• At least 2-3 years medical claims auditing experience.
• Having UAE experience is an added advantage.
• Good knowledge of insurance protocols.
• Should have good IT skills.
• Presentation and/or good communication skills to deliver feedback on audit findings