Quality Auditor- Ed Profee

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start **Caring. Connecting. Growing together.**

SME would be responsible for reviewing documentation in the electronic medical record and assigning and sequencing ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of IP Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. SME would be participating in the compliant physician query process and will collaborate with the Clinical Documentation Integrity Specialist (CDIS) team regarding clinical validation queries and the reconciliation process as applicable.

Jobs in this function provide coding and coding auditing services directly to providers. This includes the analysis and translation of medical and clinical diagnoses, procedures, injuries, or illnesses into designated numerical codes. *Employees in jobs labeled with ‘SCA’ must support a government Service Contract Act (SCA) agreement. Work is frequently completed without established procedures.

**Primary Responsibilities**:

- Works independently
- May act as a resource for others
- May coordinate others' activities
- Comply with the terms and conditions of the employment contract, company policies and procedures, and any and all directives (such as, but not limited to, transfer and/or re-assignment to different work locations, change in teams and/or work shifts, policies in regards to flexibility of work benefits and/or work environment, alternative work arrangements, and other decisions that may arise due to the changing business environment). The Company may adopt, vary or rescind these policies and directives in its absolute discretion and without any limitation (implied or otherwise) on its ability to do so

**Required Qualifications**:

- Life Science or Allied Medicine Graduates with certification from AAPC or AHIMA
- Medical Coding Background
- CPC/CCS Certified
- Minimum 5 to 10 years in coding and Audit experience
- Extensive work experience within own function
- Knowledge of, but not limited to, current Official Coding Guidelines and methodologies, the ICD-10-CM/PCS coding systems and conventions
- Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results
- In-depth knowledge of complex medical and coding concepts encountered in an Academic Medical Canter
- Solid communication skills (interpersonal, verbal and written)
- Solid analytical thinking skills
- Demonstrates critical thinking skills, and ability to interpret, assess, and evaluate provider documentation
- Proven self-motivated and demonstrated capacity to work independently without close supervision. This position has the potential to work remotely
- Must be able to work flexible hours which may include weekends as required to meet business needs.
- Ability to quickly analyze a situation, problem solve and prioritize
- Familiarity with the external reporting aspects of healthcare
- Knowledge of external auditing programs; ex.: Recovery Audit Contractor (RAC), Office of the Inspector General (OIG), third-party payors
- Ability to review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission
- Ability to determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes
- Ability to identify cases with clinical indicators that may require provider documentation clarification and/or specificity in order to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows
- Ability to analyze code assignment and sequence to assure proper assignment; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign
- Ability to analyze medical record documentation for optimum severity of illness and risk of mortality scores
- Ability to confirm Admission-Discharge-Transfer (ADT) information and correct when necessary
- Ability to suggest and assist with workflow process improvements as appropr