Akhila Paul

Medical claims Auditor / CDI specialist - CPMA

Canadian Specialist Hospital

05.2021 - 05.2025

Documentation Review & Accuracy: Ensure that services ordered by physicians and rendered to patients are accurately billed and supported by documentation in the clinical record in both IP / OP claims.
Assist the inpatient (IP) coding team in ensuring documentation compliance for Diagnosis-Related Group (DRG) negotiations, readmission cases, and long-term stay cases.
Review medical records, claims forms, lab results, and insurance forms for accuracy and completeness.
Review the medical records and policy exclusion documentation for non-covered services before submitting the claim.
Audit medical coding processes and procedures to ensure compliance with healthcare standards.
Review assigned ICD-10-CM codes to ensure they accurately describe each documented diagnosis and/or procedure according to established coding guidelines.
Review billed claims to ensure they are coded accurately and processed in accordance with insurance standards.
Audit & Compliance: Assist in the annual payer audit process by preparing comprehensive audit reports based on findings and participating in final negotiations prior to accepting audit recovery outcomes.
Ensure compliance with coding standards and healthcare regulations.
Monitor and report on documentation improvement metrics and outcomes.
Participate in quality improvement initiatives related to clinical documentation.
Report non-compliant documentation and internal audit remarks to the Quality Director and Chief Medical Officer.
Education & Training: Educate staff about new coding guidelines as they are implemented.
Provide feedback and conduct post-audit training sessions for physicians based on audit findings.
Assist in the development and execution of physician education strategies to improve clinical documentation.
Provide ongoing feedback to physicians and other providers regarding coding guidelines and requirements.
Collaboration & Communication: Collaborate with healthcare providers to clarify and improve documentation.
Actively communicate with providers to clarify information and to communicate documentation requirements for appropriate diagnoses.
Engage and consult with Physician Advisors and leadership when needed to resolve issues regarding documentation improvement.
Engage with Care Coordination and Quality Management teams to evaluate and spearhead documentation improvement opportunities.
Continuous Improvement: Recommend procedural improvements and training opportunities to management.
Assist in the development and implementation of CDI policies and procedures.
Stay updated on changes in healthcare regulations and coding standards.
Participate in educational opportunities to update job knowledge and stay abreast with changes in the field.

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