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Medical Coding Auditor II

November 10, 2023
Job Type
Work Setting
Remote / Home-based


At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: 

As a member of our medical audit team, the Medical Coding Auditor II - Inpatient DRG will have an opportunity to make a direct contribution to the company’s success, and your own, in our rapidly growing healthcare business. You will leverage your MS-DRG and APR-DRG coding knowledge and medical claims experience from an inpatient setting to identify client records with billing coding issues and recovery opportunities.  In addition, you will help identify and refine new issues for Performant to present to our clients for audit strategy, assist in developing training material or assist in training for new issues.

Key Responsibilities

  • Objectively and accurately conduct coding reviews on medical records for assigned client audit contract while meeting compliance, productivity and quality expectations.
  • Appropriately refer reviews for clinical validation.
  • Enter and update all contract and/or review findings a supporting documentation into the audit processing system.
  • Write logic/parameters for system edits to detect incorrect coding over payments, aberrant and abusive coding patterns.
  • Proof of concept development and data analysis of reports for potential edit development.
  • Monitor CMS and major payer coding and reimbursement policies.
  • Assist in identifying new issues for audit, perform research to validate new issues, and provide new rules, regulations and applicable Medicare or program language and explanation.
  • Maintain a current knowledge of all Medicare and Commercial regulations, policies and procedures.
  • Maintain certifications and training required to ensure eligibility to perform audits on behalf of Performant such as coding certification(s), as well as HIPPA and other compliance training provided by Performant.
  • Develop and maintain professional working relationships within the department and cross-functionally.
  • Other duties and responsibilities as assigned.

Knowledge, Skills and Abilities Needed

  • You must possess a unique blend of medical coding experience, business aptitude, an understanding of payables/receivables, a critical eye for quality and accuracy, team spirit, and the self-drive to meet and exceed productivity goals.
  • You must enjoy spending time solving complex issues, researching, and giving attention to detail.
  • Candidates who will thrive in our collaborative environment enjoy variety in their work and are willing to learn new systems and client requirements, anytime and anywhere.
  • Typing skills, comfortable navigating and using desktop technology, as well as working knowledge of MS Office applications (Outlook, Word, Excel).
  • Possess knowledge of CMS rules and regulations.
  • Proficient in the use of MCS 1500/UB 04 forms.
  • Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10, MS-DRG coding.
  • Working knowledge of encoder.
  • Reimbursement policy and/or claims software analyst experience.
  • Familiarity with interpreting electronic medical records (EHR).
  • Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.
  • Adaptability of skills to handle any non-standard situations that may arise or apply skills in new ways as may be required to meet business needs.
  • Ability to multi-task effectively and work independently in a remote setting.
  • Excellent written and verbal communication skills.

Required and Preferred Qualifications

  • Certification as a CPC, CPC-H, CPC-P, RHIA, RHIT, CCS, or CCS-P. Other relevant certifications may be considered.
  • At least 3 years of (MS/APR) DRG coding for hospital or other acute facility setting (inpatient/SNF Facility) is required.
  • At least 2 years of direct experience in medical chart review for all provider/claim types for inpatient/outpatient.
  • At least 2 years of experience coding/auditing facility outpatient services.
  • Prior auditing experience in either a provider or payer environment is preferred.
  • Previous payer experience in a claim processing, edit development, and/or coding and reimbursement policy a plus.
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