Highmark Health Physician Coding Auditor in Erie, Pennsylvania

Company :

Allegheny Health Network

Job Description :


Plans and conducts institutional medical record, billing, research, and non-coding compliance audits for documentation, billing, and compliance with state and federal requirements (audits may include: outpatient clinics, outpatient procedures, ancillary services, activities in accordance with Stark requirements, physician professional fees or post-acute care services including homecare, outpatient hospice, infusion, and durable medical equipment). Presents audit findings to hospital/physician leadership, creates appropriate audit spreadsheets, provides educational presentations to hospital departments/physicians/ practice staff as applicable to correct audit concerns. Completes special coding billing and documentation audits.


  • Performs internal concurrent, prospective, and retrospective audits to assure that billed services are supported by documentation in the medical record and that all coding, billing, and documentation is compliant with appropriate guidelines and federal and state regulations. Develops audit detail summary spreadsheets and reports to address any coding, documentation, or financial discrepancies. (20%)

  • Conducts presentations of final audit findings to department staff, physicians, and appropriate individuals. Works with auditees on corrective action plans and educates management, physicians, utilization review/case management staff and/or hospital personnel on documentation, billing, and coding requirements. (20%)

  • Responsible for defending payor claims denials for medical necessity, coding, billing, and documentation through coordination of and participation (when appropriate) in the appeal process - RACs, ZPICs, MICs and OIG audits and other payors as assigned. (20%)

  • Performs internal concurrent, prospective, and retrospective audits to assure that research services and bills are supported by documentation in the medical record, that research activities coincide with study protocol approved by the IRB, and that all documentation is compliant with federal and state regulations. (20%)

  • May provide guidance to hospital entities and performs reviews as needed in response to external medical necessity audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, IRB, etc. (10%)

  • Post-Acute Care Auditor Only: Supports non-audit related compliance program activities for post-acute care as needed including completion of Medicare 855s and other regulatory or licensure paperwork, and research/interpretation of new/existing regulations. (10%)

  • Compliance Requirement: As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

  • Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.



  • Bachelor's Degree or equivalent education and experience.

  • 3-5 years’ experience with compliance / auditing in hospital/physician coding and documentation; or in post-acute care field dealing with regulatory environment including billing, coding, and documentation reviews; or research and review of research documentation.

  • For hospital or professional fee auditor: National certification in procedural coding, certified professional coder (CPC), RHIT, or RHIA; or willingness to pursue successful certification within 1 year.

  • For post-acute care auditor: National certification in procedural coding, certified professional coder (CPC) preferred or equivalent experience (3 years) working in post-acute care auditing / chart review and willingness to pursue successful certification within 1 year.

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