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The work of Medical Coding Auditing Specialists involves, but is not limited to: performance of routine or standard audits of all MTFs and Dental clinics assigned to DHA Markets and DHARs, such as the Data Quality Management Control (DQMC) audit; direct support to the DHA-MCPB to develop an annual work plan of medical coding audits based upon identified enterprise risk factors; when directed, performance of targeted coding and/or documentation audits of DHA Markets, DHARs, medical service lines or specialties, MTFs, or individuals; and direct support to the DHA-MCPB in performance of medical coding audits used in Government surveillance of other DHA medical coding contracts.
Education
Educational requirements for all Medical Coding Auditing Specialists consist of a minimum of one of the following:
1.2.16.4.1. An associate’s degree or higher in Health Information Management or Healthcare Administration or biological science; OR
1.2.16.4.2. A university, college, or technical school certificate in medical coding; OR
1.2.16.4.3. At least 30 semester hours’ university/college credit of a grade of “C”, “Pass”, or better, that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology; OR
1.2.16.4.4. Successful completion of an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) online or in-person coding exam preparation course that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology; OR
1.2.16.4.5. Successful completion of a training course beyond apprentice level for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision
Required/Mandatory Knowledge/Skills/Abilities
Advanced knowledge of the International Classification of Diseases, Clinical Modification (ICD-CM), and Procedural Coding System (PCS); Healthcare Common Procedure Coding System (HCPCS); and Current Procedural Terminology (CPT).
Advanced knowledge of reimbursement systems, including Prospective Payment System (PPS) and Diagnostic Related Groupings (DRGs); Ambulatory Payment Classifications (APCs); and Resource-Based Relative Value Scale (RBRVS).
Advanced knowledge and understanding of industry nomenclature; medical and procedural terminology; anatomy and physiology; pharmacology; and disease processes.
Practical knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary services (includes, but is not limited to, Laboratory, Occupational Therapy, Physical Therapy, and Radiology); and revenue cycle management concepts.
Thorough understanding of Government rules and regulations regarding medical coding, reimbursement guidelines, and healthcare fraud; commercial reimbursement guidelines and policies; coding audit principles and concepts, and potential areas of risk for fraud and abuse. Includes, but is not limited to: The Federal Register, Center for Medicare, and Medicaid Services (CMS) Local Coverage Determinations and National Coverage Determinations (LCD and NCD), National Correct Coding Initiative (NCCI) guidance, manual, and edits, Internet-Only Manuals (IOMs), and HHS-OIG publications and reports.
Practical knowledge of revenue cycle management, project management concepts, business analysis, training methods, clinical documentation improvement, and continuous process improvement processes.
Practical knowledge of Current Dental Terminology (CDT).
Required Coding Certifications:
Medical Coding Auditing Specialists are required to possess a coding certification in good standing in each of the following categories:
Professional Services Coding Certifications: ONE of the following recognized professional coding certifications:
Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Professional Coder (CPC); or Certified Coding Specialist – Physician (CCS-P). Other professional coding certifications will be considered on a case-by-case basis.
Institutional (Facility) Coding Certifications: ONE of the following recognized institutional coding certifications:
Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Inpatient Coder (CIC), or Certified Coding Specialist (CCS). Other institutional coding certifications will be considered on a case-by-case basis.
NOTE: The AHIMA RHIT or RHIA credential may be counted towards either the professional services or institutional coding certification requirement, but not both unless the individual possesses the required institutional AND professional services experience for the specific position sought.
Required Coding Auditing Certifications: EACH of the following:
AAPC: Certified Professional Medical Auditor (CPMA); AND National Alliance of Medical Auditing Specialists (NAMAS): Certified Evaluation and Management Auditor (CEMA).
Required Experience
A minimum of eight (8) years of medical coding and/or auditing experience in four (4) or more medical, surgical, and ancillary specialties within the past 15 years. A minimum of one (1) year of performance in the specialty is required to be qualifying. Multiple specialties encompass different medical specialties (i.e., Family Practice, Pediatrics, Gastroenterology, OB/GYN, etc.) that utilize ICD, E&M, CPT, and HCPCS codes.
Four (4) years of the eight (8) years of required coding experience must involve medical coding auditing functions. Auditing functions include development and execution of audit plan, conducting audit according to audit plan by reviewing required documentation and determining compliance with audit standards, communicating with stakeholders during all phases of audit, and reporting on audit findings.
Prior DOD experience is desirable.
Candidates must pass a pre-employment coding compliance test based on the required knowledge and experience with a score of 70% or better.
Travel (3-5% a year) may be required to Medical Treatment Facilities (MTF) or main government location.
Must meet the eligibility requirements for a security clearance (US citizenship is a requirement).
Must provide proof of immunizations, including COVID vaccination, required.
FOR QUALIFIED CANDIDATES MEETING THE EXPERIENCE AND EDUCATION REQUIREMENTS BUT NOT POSSESSING THE REQUIRED CERTIFICATIONS, THE COMPANY MAY BE WILLING TO SPONSOR THE REQUIRED TRAINING/TESTING FOR CREDENTIALS. SIGNING AN AGREEMENT WITH COMMITMENT TERMS WOULD BE REQUIRED.
This contractor and subcontractor shall abide by the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
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