Job highlights

- Facility Leveling Models: Deep understanding of the ACEP (American College of Emergency Physicians) point system or other internal resource-based leveling grids .
- Preferred Certification: CPMA (Certified Professional Medical Auditor) is highly preferred for this role
- Education: Associates or Bachelors degree in life sciences

Job Summary The ED Pro Facility Auditor performs complex audits on high-volume emergency encounters to ensure that Evaluation and Management (E/M) levels, procedures, and diagnoses are correctly reported. They identify revenue leakage, prevent over-coding (compliance risk), and serve as the primary educator for both the coding team and ED physicians.

Key Responsibilities

1. Dual-Scope Auditing

- Professional Fee (ProFee) Audit: Review physician documentation to ensure E/M levels PHONE_NUMBER5) are supported by Medical Decision Making (MDM) or time. Verify that professional procedures (e.g., intubation, laceration repair) are correctly coded with appropriate modifiers.
- Facility Audit: Audit the technical component of the visit. Ensure the facility E/M level accurately reflects hospital resource consumption (nursing interventions, room usage, and supplies) based on the facility's specific leveling guidelines (e.g., ACEP or AHA models).
- Charging Integrity: Verify that facility charges (IV infusions, injections, labs, and imaging) are captured and not duplicated in the E/M level.

2. Compliance Quality Control

- Root Cause Analysis: Investigate why mismatches occur between Pro and Facility levels (e.g., a Level 5 ProFee paired with a Level 2 Facility fee) and correct documentation gaps.
- Pre-Billing Retrospective Reviews: Conduct shadow audits before claims drop to ensure clean claim submission and perform retrospective reviews to identify systemic errors.
- Regulatory Monitoring: Stay current with Medicare Outpatient Prospective Payment System (OPPS) updates and National Correct Coding Initiative (NCCI) edits.

3. Provider Coder Education

- Feedback Loops:



Provide one-on-one coaching to physicians on documenting medical necessity and acuity to support higher-level codes.
- Training: Develop and deliver training modules for ED coders specifically on the nuances of ED-specific modifiers (e.g., -25 for significant, separately identifiable services).

Technical Skills Frameworks

- MDM Mastery: Expert knowledge of the 2021/2023 E/M guidelines, focusing on the three elements of MDM: Number/Complexity of Problems, Data Reviewed, and Risk.
- Facility Leveling Models: Deep understanding of the ACEP (American College of Emergency Physicians) point system or other internal resource-based leveling grids
- Claim Forms: Proficiency in both CMS-1500 (Professional) and UB-04 (Institutional/Facility) requirements.
- Software Proficiency: Experience with audit software (e.g., MDaudit, RevPoint) and EHRs like Epic (ASAP module) or Cerner.

Qualifications

- Experience: 3-5 years of specialized ED coding experience, with at least 2 years in an auditing or lead role.
- Certifications (Required):
- AAPC: CPC (Professional) AND COC (Outpatient) or CEDC (Emergency Department).
- AHIMA: CCS or CCS-P.

- Preferred Certification: CPMA (Certified Professional Medical Auditor) is highly preferred for this role.
- Education: Associate's or Bachelor's degree in life sciences

Key Performance Indicators (KPIs)

- Coding Accuracy Rate: Maintain a minimum 95% accuracy rate for both Pro and Facility audits.
- Level Distribution: Monitor Bell Curve trends to ensure the facility is not an outlier compared to national averages (preventing RAC audits).
- Denial Reduction: Percentage reduction in ED-related medical necessity and bundling denials.
- Mismatch Rate: Reducing the frequency of unsupported discrepancies between Qualified and Facility service levels.

Physical Demands Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described.

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 QA - HIM Services (Noida)
🏢 CorroHealth
📍 Noida