Position Title: Auditor/ Trainer
Location: Twenty-Nine Palms, CA
Start Date: June 1, 2011
The Auditor/ Trainer shall conduct audits of Client-coded medical records onsite at Client hospital. The
audit shall assess compliance with Client requirements and industry standards, such as use of modifiers,
procedure sequencing; and linkage of procedures to diagnosis codes to support medical necessity of
services. All training will focus on improving documentation to support accurate coding of the medical
Duties and Responsibilities:
o The audit function is retrospective; it is an assessment of a sample of the inpatient and
outpatient records with emphasis on compliance with Government regulations,
insurance requirements, and industry standards. The audit results are incorporated into
the Client’s practices and standard operating procedures to (1) improve the accuracy
and completeness of coding through (2) improved medical encounter documentation
practices and (3) continuous monitoring of contract effectiveness at the facilities.
Criteria and guidelines are set by Service Leads who have the final authority.
o The audit shall identify inaccurate/non-specific code assignments and documentation
improvement opportunities and shall make recommendations for staff training.
o Improved documentation is documentation that accurately reflects the patient/provider
interaction, the chief complaint/reason for admission, including pertinent patient and
family health and social histories, and co-morbidities affecting the specificity of final
code assignment. Baseline documentation skills are established from the audit.
o Inpatient record audits shall verify patient care documentation elements including
patient identification and demographic variables, reason for admission, disposition date,
and assignment of diagnoses, procedures documentation, and provider signature.
o Outpatient record audits, shall verify the inclusion of patient care documentation
elements including patient identification and demographic variables, chief
complaint/reason for visit, encounter date, assignment of diagnoses, procedures
documentation, and presence provider signatures.
o The Auditor/ Trainer will develop training that is specific to the clinical services provided
by the Client and will incorporate standardized training guidance to facilitate evolving
requirements (i.e. ICD-10 implementation). The Auditor/ Trainer will work in
conjunction with the Client personnel and trainers in the performance of these services.
ICD-9 and CPT codes and conventions
Inpatient and outpatient documentation
RVU/RWP documentation and coding
Residency specific issues (as applicable)
Use of HCPCS and CPT codes
Inpatient and outpatient documentation
Inpatient and outpatient query form process
Changes in industry coding conventions and nomenclature
Industry coding classification updates
o The Auditing/ Trainer will ensure the training materials are continuously updated to
relay the most current and relevant information. The curriculum shall include specific
information and examples relevant to the clinical area for which the training is provided.
o The Auditor/ Trainer will use a variety of methods to provide training, which may
include, but are not limited to, group training, one-on-one training, webinars, web
based training, power point presentations, VTC and instructional videos.
Keep up to date on coding rules and standards
Analyze data; read, interpret, and apply policies, procedures, laws, and regulations;
Read and interpret medical procedures and terminology;
Prepare reports and related documents;
Maintain working relationships with Auditor and Project Supervisor;
Maintains and complies with policies and procedures for confidentiality of all patient records.
Demonstrates knowledge of security of systems by not sharing computer logons.
Consistently supports the compliance and principles of responsibility by maintaining
confidentiality, protecting the assets of the organization, acting with integrity, reporting
observed fraud and abuse and complying with applicable state, federal and local laws and
program policies and procedures.
*The duty statements are intended to describe the general nature and level of work being performed by
individuals assigned to positions in this classification and, as such, are not intended to be construed as
an exhaustive list of duties, responsibilities and skills required of every position so classified.
Education: High School Diploma or G.E.D.
Certification or License: Possess and maintain one of the professional coding certifications issued by
AHIMA or AAPC.
Experience: Possess a minimum of 1 year of auditing experience within the preceding 2 years and
possess 1 year of HIM experience in process improvement, data quality improvement, or documentation
Knowledge, Skills and Abilities:
Prior Military Health System experience preferred.
Strong working knowledge of ICD-9-CM coding rules and standards, CPT coding guidelines,
medical terminology and Medicare reimbursement guidelines.
Strong understanding of medical terminology and anatomy.
Basic familiarity with performing PC-based data entry.
Ability to review and process information to determine conclusions, actions or compliance with
applicable laws, rules or regulations.
Substantive knowledge of and ability to use correct grammar, vocabulary, spelling, proofreading
and office terminology to compose and/or proofread correspondence, reports and materials.
Skill in communicating effectively both orally and in writing.
Work is generally performed within a general office environment, with standard office equipment
available. Lighting and temperature are adequate. Noise levels are typically quiet to moderate. There
are no hazardous or unpleasant conditions caused by noise, dust, etc.
Ability to sit for long periods of time.
Ability to lift, push or pull up to 20 pounds.
Occasional bending, stooping, kneeling, crouching, reaching.
Occasionally required to stand, walk or climb stairs.
Ability to withstand the pressure of continual deadlines and receipt of work with variable
Ability to concentrate and maintain accuracy in spite of frequent interruptions.
Manual dexterity: use hands to finger, handle, or feel objects, tools or controls.
Specific vision abilities required by the job include close vision, distance vision, color vision,
peripheral vision, depth perception, and the ability to adjust focus.
Ability to talk and hear.
*The physical demands described here are representative of those that must be met by an employee to
successfully perform the essential functions of this job. Reasonable accommodations may be made to
enable individuals with disabilities to perform the essential functions.
Other: This position profile identifies the key responsibilities and expectations for performance. It
cannot encompass all specific job tasks that an employee may be required to perform. Employees are
required to follow any other job related instructions and perform job related duties as may be
reasonably assigned by his/her supervisor.