The auditor/ trainer shall possess and maintain certifications issued by a nationally recognized certifying professional body for coding professionals. An apprenticeship certification is not considered acceptable.
The contractor’s professional staff shall possess a minimum of 2 years of experience working in their discipline.
Be a U.S. Citizen.
MEDICAL RECORD AUDITS
The auditor/ trainer shall conduct audits of government coded medical records as stated in the individual task orders. The audit shall assess compliance with Department of Defense (DoD) requirements and industry standards, such as the use of modifiers, procedure sequencing and linkage of procedures to diagnosis codes to support medical necessity of services. The contractor shall perform the audits in accordance with the Bureau of Medicine and Surgery Instruction 6150.38 A (BUMEDINST 6150.38A) (or current version).
The auditor/ trainer’s audit shall identify inaccurate/non-specific code assignments, document improvement opportunities and make recommendations for staff training. Improved documentation accurately reflects the patient/health care provider’s interaction, the chief complaint/reason for admission (including pertinent patient/family health and social histories) and co-morbidities affecting the specificity of final code assignment. The audit report shall describe the gap between the medical record documentation and the required baseline clinical documentation. This information shall be used to improve clinical documentation through provider training.
The auditor/ trainer shall pull the records for the audit based on the list provided by the task order primary Government POC. The task order primary Government POC will coordinate specific audit dates and provide a list of the records to be audited.
The auditor/ trainer shall verify patient identification and demographic information, chief complaint/reason for visit, encounter date, assignment of diagnoses, procedures documentation and provider’s signature for all outpatient record audits. The audit shall include a comparison of the auditor’s coded record against the original coded record and a comparison of Relative Value Unit (RVUs).
The primary focus of training is to increase the accuracy of medical encounter coding by improving code assignment and clinical documentation.
The auditor/ trainer shall work with the government to develop training that is specific to the clinical services provided by the MTF and shall incorporate standardized Bureau of Medicine and Surgery (BUMED) training guidance provided in the Coding Program Management and Training Guidelines to facilitate evolving requirements. The contractor shall work with the MTF personnel and the AHLTA sustainment trainers in the performance of these services. Training topics shall include the current ICD version; Current Procedural Terminology (CPT) codes and conventions; inpatient and outpatient documentation; RVU/RWP documentation and coding; residency specific issues (as applicable); use of Healthcare Common Procedural Coding System (HCPCS) and CPT codes; outpatient query processes; and industry coding classification updates.
The auditor/ trainer shall ensure 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.
The auditor/ trainer shall not include instruction on how to use the government systems such as AHLTA, Composite Health Care System (CHCS), or Coding Compliance Editor (CCE) in their curriculum. The contractor shall inform the task order Government POC and the COR in writing of system related issues brought up during training.
The auditor/ trainer shall participate in continuous process improvement with AHLTA sustainment trainer and aid the health care providers in determining the best process for entering information into the system.
The auditor/ trainer shall incorporate audit findings and feedback from health care providers (to include residents and interns), clinical staff and government coders into their training.
The auditor/ trainer shall provide updates and revisions to any templates or tools used by the health care providers related to coding.
The auditor/ trainer shall use a variety of methods to provide training, which may include, group training, one-on-one training, webinars, web-based training, power point presentations, Defense Collaboration Services (DCS) and/or instructional videos. The government reserves the right to record any training session or copy any of the training materials provided by the contractor for educational purposes.
The auditor/ trainer shall identify and provide a list of teaching tools/equipment required from the government at least two weeks in advance of training.
The auditor/ trainer shall advise the task order Government POC and the COR in advance of developing the training schedule if any provider requires immediate training based on the audit results.
Peak Health Solutions, an AMN Healthcare company, is an EEO/AA/Disability/Protected Veteran Employer. We encourage minority and female applicants to apply