Facility: VIRTUAL-GA
Job Summary
Under direction of the Executive Director of Coding Assurance/Compliance, reporting directly to the Coding Assurance Manager (Professional Services or Outpatient Hospital): Support and provide coding and compliance training to physicians, clinical personnel, billing, and/or other hospital staff. Establish effective communication with physicians, clinical staff, and/or hospital staff to address documentation, coding, and reimbursement issues. Conduct medical record reviews to ensure accurate, ethical documentation, coding, charging and billing practices. Audit physician and/or hospital medical records and charges to ensure compliance with coding and regulatory standards. Educate physicians, clinical staff, and/or hospital staff on appropriate documentation as required by medical review and governmental agencies. Develop written policies promoting WellStar's commitment to compliance and specific areas of potential fraud and abuse. Use knowledge of coding and compliance guidelines to identify potential billing / reimbursement issues. Participate in special audits as instructed. Work as a team member within Coding Assurance and all other departments. Document work processes as required. Perform other duties as assigned.
Core Responsibilities And Essential Functions
Perform multi-specialty coding/documentation reviews to identify: documentation improvement opportunities, patterns of over/under coding, other potential risk areas related to services documented as well as perfom medical necessity and charge reviews of hospital outpatient services * CPT-4 and ICD-9 * Chart documentation * Evaluation and Management * Federal and state regulations governing billing (medical necessity, CCI edits etc) * Support WellStar Internal Compliance Plan * Review claim charge data and edits to determine line items lacking medical necessity * National/Local Coverage Determination and Official Coding Guideline reviews appropriate for the procedure /test in question * Medical record documentation review to identify any medically necessary diagnoses * Contact physician for additional medically necessary diagnoses support by their clinic documentation, but not submitted to facility * Update claim charge data with additional diagnoses from medical record or updated order received from the physician * Communicate with PFS, Revenue Management, and other hospital departments as need to resolve additional failed claim issues Provide support to the billing and insurance departments and EMR Team, provide research, interpretation, and education on new/revised regulations * Review CMS regulations and official coding guidance to stay abreast of coding/billing regulatory changes * Summarize National/Local Coverage Determinations * Educate as appropriate * Re-submission of claims * Revenue Cycle Reviews * Denial/appeal follow-up * Validation of charges/payments (Maintain Coding Helpline (.Answer , Resolve ,Respond to all questions, comments, observations) * Communicate and provide compliance education of all Medicare/Medicaid regulations ( ABN , CLIA,CCI , LMRP,MSP, Co-pays, Screening tests) Address over coding and/or under coding issues individually with physicians and other providers through education and monitoring as well as perform focused reviews * Provide real-time updates to physician practies regarding changes in regulations, guidelines, claim edits, etc. * Provider Meetings * Presentations (Develop and present coding/compliance education material via Lunch and Learn Classes, Coding Newsletter, Group Memos ) * Rounding with physicians * Conduct data sampling, auditing, and reporting on all reviews associated with the Annual OP Coding Assurance Audit plan * Audit focus is on outpatient hospital ICD9CM and CPT4 coding as well as National and Local Coverage Determinations, OIG Workplan, and any other federal/state regulations * Research official guidelines to plan scope of focused reviews. * Communicate trends and audit findings with the respective hospital departments and educate as appropriate * Benchmark comparisons and identification of trends and errors in coded data * Review data analytics * Identify revenue enhancement opportunities * Trend and analyze denials, provide feedback and education to all entities * Identify, Find Solution, communicate solution with both external and internal customers as required * Distribution and analaysis of reports with employed physicians * Diagnosis, procedural, APC/DRG, charge data, admission/discharge data * Track trends and errors to identify amount of lost revenue and/or overpayments * Provide and participate in error resolution to correct aberrancies in coding and/or charge practices * Assist with the implementation of new processes as needed to assure error resolution Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.
Required Minimum Education
High school diploma Required and Bachelor's Degree in Health Information Management, Business Required or Associate's Degree in Health Information Management, Business Required or other health care related field preferred Preferred
Required Minimum License(s) And Certification(s)
All certifications are required upon hire unless otherwise stated.
- Cert Coding Spec or Cert Coding Spec - Phys Based or Cert Prof Coder or Cert Prof Coder - Hospital OP or Reg Health Information Admin or Reg Health Information Tech
Additional License(s) And Certification(s)
Required Minimum Experience:
Less than 1 year of physician office and/or hospital-based inpatient/outpatient services coding experience required. Required and A combination of 5 years of comparable experience with hospital and/or physician coding, billing and reimbursement experience may be substituted for an Associate's degree Required
Required Minimum Skills
Extensive knowledge of medical terminology, CPT-4 procedural coding (including Level II HCPCS), ICD-9-CM coding, and all coding and billing guidelines. Hospital or Physician billing experience with focus on government payors. Extensive knowledge of the Documentation Guidelines for Evaluation and Management (physician specific staff). Extensive experience with medical record chart review and/or extraction for physician or hospital billing. Extensive experience with Medicare, Medicaid, and reimbursement rules and regulations. Experience with management information systems and medical software. Competent in Microsoft Word and Excel software in a Windows environment (Experience with Microsoft Access Is a plus). Must demonstrate extensive experience with coding of Evaluation and Management services (physician specific staff) and surgical procedures.
