Internal Clinical Documentation Analyst- Health First Medical Group LLC- Coding- Full Time

Health First Rockledge, FL

About the Job


Providing Quality / No Harm, Customer Experience, and Stewardship under general supervision. Assist Compliance management, monitor compliance by completing system wide investigations, detailed prospective and retrospective compliance quality assurance audits/internal chart reviews, compliance risk assessments, and compliance regulatory training.


Primary Accountabilities

  • This position will have primary audit responsibility for the Health First Medical Group and provide secondary audit support to other Health First entities as needed.
  • The Clinical Documentation Analyst may travel locally approximately 25% of the time. 
  • The Analyst is expected to have general knowledge of the seven elements of a Compliance Program.
  • Independently conducts coding and documentation analysis of practitioner charts according to the practitioner audit schedule and methodology.
  • Apply coding and documentation standards to ensure that all documentation for each encounter selected is evaluated for consistency with the nature of the patient encounter and that the medical necessity is well supported.
  • Evaluate occurrences of deficiencies and/or inconsistencies in medical record.
  • Monitors, identifies and tracks practice patterns and trends which may lead to organizational non-compliance and reports to leadership as needed. 
  • Works to implement best audit and compliance practices to assist in mitigating organizational risks.
  • Provides education and training materials to practitioners and their staff regarding compliance with coding and documentation requirements up to and including CPT, HCPCS and ICD-9. This may include one on one and/or group sessions with feedback from reviews performed, providing recommendations for improvement when needed.
  • Takes the lead on special tasks and report to leadership when appropriate.
  • Initiate special audits when required, follow through with the overall review and report to HFMG Compliance officer and associated providers.
  • Provides weekly written or oral reports on status of open activities and issues.
  • A minimum of an Associates Degree with three years of healthcare auditing or vocational certificate for a Billing and Coding program along with a CPC certification,
  • Certifications required upon hire\: CPC or CPC Certification required within one year of date of hire
  • Certifications preferred\:  Certified Evaluation and Management Coder (CEMC)
  • Experience in an integrated healthcare delivery system preferred
  • Demonstrated expertise in accurately assessing evaluation and management documentation and coding
  • Working knowledge of CMS billing and documentation rules for DRGs, APCs, and CPTs coding
  • Demonstrates organizational, verbal, written, analytical and problem solving skills
  • Demonstrates effectiveness to communicate with management and healthcare practitioners
  • Demonstrates proficiency in Microsoft Office (Word, Excel, PowerPoint) presentations