Medical Auditor

1 day ago

Miami, Florida, United States ClareMedica Full time
Position Summary

Under the direction of the Auditor Supervisor and Director of Billing & Coding, the Medical Auditor reviews services provided and compares them to EHR and billing records to determine accuracy. The Medical Auditor performs quality reviews of outpatient medical records to validate ICD-10 diagnoses, procedures, and CPT/CPT II coded services. They identify under- and over-coded services, prepare reports of findings, and educate management to improve coding practices. The Medical Auditor ensures appropriate coding, compliance documentation, and optimized billing while staying updated on regulatory and procedural changes.

Essential Job Functions
  • Supports and implements the company's vision, mission, and values.
  • Prioritizes workload to ensure timely completion of responsibilities.
  • Performs all job functions professionally and courteously.
  • Promotes a culture of service excellence and accountability.
  • Communicates with providers to clarify diagnoses, procedures, and documentation requirements.
  • Reviews assigned ICD-10-CM and CPT-4 codes, ensuring accuracy and compliance with guidelines.
  • Monitors coding accuracy and maintains quality standards.
  • Tracks and addresses coding issues and inaccuracies.
  • Reviews medical records to verify documentation and coding for services rendered.
  • Ensures compliance with federal, state, and local coding/documentation guidelines.
  • Identifies and resolves documentation or coding discrepancies.
  • Verifies the accuracy of submitted diagnosis codes based on documentation and rendered services.
  • Performs comprehensive medical record reviews for completeness and accuracy.
  • Monitors and reconciles documents required for data entry; returns incomplete or questionable records.
  • Provides technical education and serves as a subject matter expert on coding and documentation.
  • Educates team members on compliance and regulatory requirements.
  • Reviews payment denials, underpayments, and takebacks; guides appropriate resolution.
  • Collaborates with other departments to resolve coding issues and ensure accurate claim payment.
  • Uses audit results to provide data-driven feedback to providers and management.
  • Ensures accuracy and completion of all encounter forms.
  • Assists business services with maintaining necessary data files.
  • Complies with all organizational policies and procedures
  • Performs other related duties as assigned.
Qualifications

Education / Experience:

  • Minimum of 3 years of coding, billing, and audit/chart review experience required.
  • Certified Professional Coder (CPC) — required.
  • Certified Professional Medical Auditor (CPMA) — required.
  • Certified Risk Adjustment Coder (CRC) — preferred.
  • Must maintain current coder/auditor certification.
  • Strong understanding of medical terminology, CPT, HCPCS, and ICD coding.
  • Experience with Medicare Advantage, Medicaid, and outpatient coding.
  • Working knowledge of billing for multi-discipline practices and general computer systems.

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