Documentation Quality Auditor IV

Job Summary:

Contributes to coding quality audits by conducting special projects, audits, reviews, and/or monitoring of assigned lines of business or scope to monitor the accuracy and quality of coding and documentation, and following guidelines and procedures to ensure alignment with state and federal regulatory and reimbursement requirements, current documentation, and coding guidelines. Contributes to audit analysis and report writing by comparing coding and documentation across the enterprise to identify potential risks and remedies, and preparing written and/or generated audit reports detailing all noted opportunities. Contributes to enhancing coding integrity by aiding teams in their assigned lines of business or scope in developing, implementing, and monitoring new processes and workflows that support regulatory needs and requirements, organizational goals, and business objectives. Ensures compliance by following national, state, and KP-specific coding, billing, and documentation guidelines/guidance for KPs leadership, attorneys, physicians, coders, compliance, and billers to help coordinate consistent and accurate implementation and compliance with external regulations.

Essential Responsibilities:

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.

• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.

• Contributes to audit analysis and report writing by: comparing coding and documentation across the enterprise to identify potential risks and remedies independently; conducting trend analyses to identify patterns and variations in coding practices, key compliance drivers, liabilities, and performance indicators (e.g., adherence to standards, incorporation of new regulations), and beginning to coordinate team members to do the same; and preparing written and/or generated audit reports using standardized language detailing all noted opportunities, and providing education as needed.

• Contributes to coding quality audits by: conducting special projects, audits, reviews, and/or monitoring of assigned lines of business or scope independently to monitor the accuracy and quality of coding and documentation; using processes to assess accuracy and completeness of coded documentation integrity; and following guidelines and procedures to ensure special projects, audits, reviews, and/or monitoring align with state and federal regulatory and reimbursement requirements, current documentation, and coding guidelines, and guiding team members to do the same.

• Ensures compliance by: following national, state, and KP-specific coding, billing, and documentation guidelines/guidance for KPs leadership, attorneys, physicians, coders, compliance, and billers to help coordinate consistent and accurate implementation and compliance with external regulations; attending national committees; and participating in National Compliance programs to assure maximum utilization of coding resources when conducting special projects, monitoring, reviews, and/or audits.

• Contributes to enhancing coding integrity by: assisting with the identification of coding/documentation trends and opportunities; leveraging expert knowledge to aid teams in their assigned lines of business or scope in developing, implementing, and monitoring new processes and workflows that support regulatory needs and requirements, organizational goals, and business objectives; and leading the process of communicating up-to-date and accurate regulation, policy, and guideline changes impacting coding and documentation to all impacted employees.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management

• Attention to Detail

• Business Knowledge

• Communication

• Critical Thinking

• Cross-Group Collaboration

• Decision Making

• Dependability

• Diversity, Equity, and Inclusion Support

• Drives Results

• Facilitation Skills

• Health Care Industry

• Influencing Others

• Integrity

• Learning Agility

• Organizational Savvy

• Problem Solving

• Short- and Long-term Learning & Recall

• Teamwork

• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Audits

• Compliance Management

• Data Quality

• Execution Excellence

• Health Care Compliance

• Health Information Systems

• Information Gathering

• Internal Audit Processes

• Maintain Files and Records

• Medical Coding

• Medical Terminology

• Quality Assurance and Effectiveness

• Quality Improvement

• Written Communication

Minimum Qualifications:

• Minimum two (2) years of experience in International Classification of Diseases (ICD)-10-Clinical Modification, Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding, including chart auditing, applying diagnoses and/or procedure coding, and/or conducting coding reviews.

• Associates degree in Health Information Management, Health Care Administration, or related field AND minimum five (5) years of experience in health care compliance, health care operations (quality, risk), audit, insurance/health plan governance, coding, medical record review, or a directly related field OR Minimum six (6) years of experience in health care compliance, health care operations (quality, risk), audit, insurance/health plan governance, coding, medical record review, or a directly related field.

• Registered Health Information Technician required at hire OR Certified Coding Specialist - Physician Based required at hire OR Registered Health Information Administrator required at hire OR Certified Professional Coder required at hire OR Certified Coding Specialist required at hire

Preferred Qualifications:

• Risk Adjustment Certification.

• Five (5) years of auditing experience.

COMPANY: KAISER

TITLE: Documentation Quality Auditor IV

LOCATION: San Jose, California

REQNUMBER: 1456952

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.