Job Summary: The Medical Record & Coding Auditor is responsible for performing annual, periodic or other focused medical record audits as requested to oversee the quality and accuracy of multi-specialty provider group, inpatient and outpatient coding and documentation. This position requires effective communication with all stakeholders and excellent organization skills to ensure timeliness and accuracy of response requests, as well as continual program development through training, education and process improvement for providers.

Essential Job Functions & Accountabilities:

1. Performs medical record audits with a primary focus on coding and medical documentation regulatory compliance.
2. Performs documentation audits for both Evaluation and Management Coding (E&M coding) for outpatient and inpatient services and surgical procedures to ascertain the accuracy and completeness of the Providers E/M and Procedure coding.
3. Coordinates with outside audit vendor(s) regarding accurate and timely coding and compliance audits of Provider documentation.
4. Reviews audit results with Providers, Department Chairs, Service Line Administrators, and/or Coding Staff.
5. Assists with the development of training materials for compliance education and training.
6. Provides education and training to Providers (new and established) and others as indicated regarding documentation, coding and data interpretation.
7. Serves as a resource person to obtain information on accurate and ethical coding documentation standards, guidelines, and regulatory requirements.
8. Communicates coding updates published in third-party payer newsletters, bulletins, and provider manuals.
9. Maintains knowledge of new trends and documentation guidelines by attending seminars and webinars as applicable.
10. Job description is not an all-inclusive list of duties and may be subject to change with or without notice. Staff are expected to perform other duties as assigned.
11. Must be able to complete all job duties and functions of the role with or without assistive/adaptive devices, and/or reasonable accommodations.
12. Work environments may differ based on job functions and location. Work is subject to schedule changes and/or variable work hours.