Job Details

Job Title

Performs quality reviews and audits to ensure compliance with DRG validation, ICD-10/PCS, and CPT coding guidelines.

Job Summary

Coordinates with department leadership to ensure standards are met in accordance with department and organization policy. Contributes to improving the processes and infrastructure of the department. Demonstrates proficiency in facilitation and interpersonal communication, organizational skills, prioritization of tasks, professionalism, and educating and training as required. Uses in depth understanding of the CQR quality workplan to will promote compliance and awareness of the plan. Acts as a subject matter expert (SME) in national coding guidelines for hospital inpatient and/or outpatient and will ensure compliance with those guidelines along with all company coding policies. Uses performance improvement analyses to improve the accuracy, integrity and quality of patient data, ensure minimal variation in coding practices, and improve the quality of physician documentation within the body of the medical record to support code assignments which results in appropriate reimbursement and data integrity.

Job Requirements

Education and Work Experience:

• High School Education/GED or equivalent: Required
• Associate's/Technical Degree or equivalent combination of education/related experience: Preferred
• Three years' acute care inpatient and/or outpatient coding experience: Required
• Three years' coding auditing/monitoring experience: Preferred

Licenses/Certifications:

• Certified Coding Specialist credential through AHIMA: Required

Essential Functions:

• Performs regularly scheduled quality reviews and audits per departmental policies and procedures (routine, pre-bill, policy driven, targeted, and post-bill) for hospital inpatient and/or outpatient coding. Facilitates the coder audit appeal process, providing rationale and education to the coding team as required. Performs ad hoc quality reviews, such as targeted DRG reviews, and special projects as assigned by management.
• Prepares detailed audit reports outlining findings, recommendations, rationale, and corrective actions needed. Facilitates the coder appeal process. Assists team members with coding questions and provide resolution guidance.
• Assists in ensuring coding staff adherence with coding guidelines and policy, both internal and vendor teams. Demonstrates and applies expert level knowledge of medical coding practices and concepts. Communicates appropriately with manager and all stakeholders as required.
• Identifies and communicates educational opportunities to manager. Maintains working knowledge of workflows, systems, and tools used in the department. Reviews all official data quality standards, coding guidelines, company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current.
• Maintains up-to-date knowledge of medical terminology, coding guidelines, quality standards, regulatory changes, etc. that affect the audit process. Assists in creation and maintenance of a positive working environment, including effective communication and setting an appropriate professional example.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit

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