Clinical Documentation and Coding Auditor

Location: Remote
Supervisor: Practice Manager
Employee Classification: Non-Exempt (Hourly), Part-Time
Hours: Part-Time, up to 20 hours per week
Compensation: $29.71/hour

Primary Function:

The Clinical Documentation and Coding Auditor will contribute to maintaining the highest standards of accuracy, privacy, and efficiency in our documentation and coding processes. They will review therapy and psychiatry notes and charting to ensure compliance with industry regulations, best practices, and billing guidelines. The position of Clinical Documentation and Coding Auditor requires an individual who is detail-oriented and possesses an analytical mindset. This individual should also come with a background encompassing coding expertise, audit experience, and clinical proficiency.

Essential Functions:

• Conduct comprehensive audits of therapy and psychiatry notes and charting to verify accuracy, completeness, and adherence to relevant legal and regulatory requirements.
• Review and assess coding practices to confirm alignment with current coding guidelines and appropriate diagnosis and procedural coding for mental health services provided.
• Monitor documentation practices to ensure compliance with privacy laws (e.g., HIPAA) and relevant healthcare regulations.
• Provide constructive feedback and education to clinicians and administrative staff to improve documentation practices and coding accuracy.
• Generate audit reports and analysis to identify trends, areas for improvement, and potential risk areas in clinical documentation and coding processes.
• Collaborate with the clinical team, billing department, and administrative staff to address documentation-related issues and implement corrective actions.
• Stay updated and aware of changes in coding and billing regulations, mental health documentation guidelines, and industry best practices.
• Provide guidance and training to clinical staff on proper documentation practices, coding accuracy, and compliance measures to foster a culture of excellence.

Performance Requirements: 

Knowledge

• Knowledge of mental health coding systems (e.g., CPT, ICD-10) and their applications.
• Demonstrate a strong understanding of healthcare privacy regulations (e.g., HIPAA) and compliance standards related to mental health documentation and coding.
• Demonstrate a strong understanding of mental health therapy and psychiatry services and associated clinical documentation requirements.
• Knowledge of or willingness to learn the practice’s policies and procedures. 
• Knowledge of or willingness to learn industry specific terminology and insurance practices. 
• Knowledge of grammar, spelling, and punctuation, for effective and appropriate communication.
• Knowledge of web-based computer programs and applications in an Apple/Mac environment.

Skills

• Possess auditing skills to methodically examine documentation, coding practices, and billing processes, identifying anomalies and ensuring adherence to best practices.
• Excellent written and verbal communication skills to provide effective feedback and interact with various stakeholders.
• Meticulous in reviewing and analyzing clinical documentation for accuracy and completeness.
• Manage multiple medical records, audits, and tasks simultaneously
• Navigate coding challenges and discrepancies, employing critical thinking to resolve issues while maintaining compliance and accuracy.

Abilities 

• Ability to interpret data and generate actionable insights from audit findings.
• Ability to adapt to changing requirements and prioritize tasks effectively.
• Ability to work effectively as a team member, and to communicate clearly, compassionately, and respectfully, with medical and mental health professionals, as well as with administrative support staff.
• Ability to manage multiple medical records, audits, and tasks simultaneously.
• Ability to function proficiently in a web-based computer environment.
• Show compassion: Employees may see people during moments of trauma or crisis, where they and their family are vulnerable or in pain.
• Demonstrate patience: Being patient with people who may have trouble communicating or understanding what is happening is important.

Minimum Qualifications:

• Previous experience in clinical documentation and coding audits is preferred.
• Coding certifications (e.g. CPC, CCS) and mental health-specific certifications (e.g. CMHC, LCSW) are a plus.
• Demonstrate a strong understanding of HIPAA policies and regulations.
• Demonstrate a strong attention to detail and organization.
• Follow policies and procedures to contribute to the efficiency of the practice, taking initiative to suggest and develop those that may be needed.
• Demonstrate strong computer skills including web based systems.
• Ability to work with Mac OS & Google Workspace.
• Work well independently.
• Demonstrate competence and humility in terms of race, ethnicity, gender, sexual orientation, religion, class, ability et al.
• Demonstrate commitment to the preservation of a workplace which embraces diversity.

Equipment Operated: Standard office equipment, including computers, copiers, printers, telephones, etc.

Work Environment: When working from a PMHW office, the position is in a well-lit office environment. Varied activities including sitting, standing, walking, reaching, bending, and lifting.

Mental and Physical Requirements: Involves sitting approximately 90 percent of the day, walking or standing the remainder. Ability to tolerate mental and emotional distress as an anticipated aspect of the position. May require working under stressful conditions.

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This description is intended to provide only the basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities, and working conditions may change as the practice’s needs evolve. Regular and predictable attendance is an essential function of every job.

The requirements described above are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. By signing below, you acknowledge that you are able to perform the Essential Functions of this job, with or without accommodation. If an accommodation is needed, you acknowledge that you have an opportunity to discuss this with Human Resources.