Blanchard Valley Hospital
Findlay, Ohio
PURPOSE OF THIS POSITION The primary purpose of the Professional Coding Integrity Specialist (PCIS) is to review, enter and/or modify charges as appropriate, including review of clinical documentation to ensure charge is supported and/or to determine specific charge/modifier assignments, for designated clinical areas. JOB DUTIES/RESPONSIBILITIES Duty 1: Review, enter and/or modify charge on encounters to ensure accurate and compliant and optimal charge capture in a time-sensitive manner for designated clinical service lines. Review clinical documentation to ensure charge is appropriately supported and/or to determine the assignment of the accurate charge, modifier, E&M levels, etc. Assign ICD-10 diagnosis codes as appropriate. Work "exception" accounts (e.g. canceled accounts, combined, unique modifier or charge rules requiring review, etc.) through review of clinical documentation and/or collaboration with appropriate resources, as needed, to resolve. Duty 2: Support resolution of claim-scrubber edits (Quadax) resulting from charges entered by the Revenue Integrity Validation team; collaborate with clinical areas, coding, PFS, etc. to support resolution of edits; trend, identify opportunities, and collaborate with RI Educator and/or Claims Resolution Specialist to avoid/reduce future edits. Support Condition 44 notifications (inpatient to observation status) process by properly modifying charges and calculating hours etc. Duty 3: Track and quantify revenue impact to organization as a result of charge corrections made, including impacts from modifications to processes. Duty 4: Identify opportunities related to clinical documentation and/or other system enhancements to support optimal and accurate charge processes; collaborate with CDI Specialist, Claims Resolution Specialist, Revenue Integrity Auditor, Revenue Integrity Educator, clinical area, and other areas to support resolution of issues. Duty 5. Demonstrate proficient knowledge of federal, state and third party charging guidelines of clinical areas supported by the Revenue Integrity Validation team to ensure optimal, accurate and compliant charging. Understand changes to applicable coding and billing regulations, including annual IPPS/OPPS revisions, by resourcing credible references (i.e. CMS website, Craneware, publications, professional contacts, reliable internet sources, seminars, etc.). Collaborate with clinical areas, Revenue Integrity Team, Coding Integrity Team and/or other impacted areas to support implementation of changes. Duty 6: Participates in system testing as a result of upgrades, changes, enhancements, new application implementations, etc. that may impact Revenue Integrity Validation processes. Duty 7: Regularly attends and actively participates in in-services, organizational and department meetings and continuing education programs as offered in order to remain current with organizational and industry changes and best practice. Communicate and disseminate information to other departments as applicable. REQUIRED QUALIFICATIONS An Associate's degree in a related field including, but not limited to, health information, business or related clinical profession preferred or 1-2 years' experience from which comparable knowledge and abilities have been acquired. Coding certification (CCA or CPC) required or obtained with 9 months of hire date Knowledge of medical terminology and anatomy and physiology required. Knowledge of CPT/HCPCS/APC coding systems, appropriate use of applying modifiers, CPT Assistant, LCD/NCD and ICD-10 required. Ability to research, review and interpret Federal, State and Local billing regulations required. Familiarity with utilization of computers and commonly used applications, including Microsoft Office Suite, (Windows, Excel, Word, Outlook), electronic health record, internet required. Ability to track and monitor data to identify trends pertaining to charge issues. Excellent organizational, time management and problem-solving skills required; detail oriented and follow through. Positive service-oriented interpersonal and communication (written and verbal) skills required. PREFERRED QUALIFICATIONS Other certifications applicable to primary clinical service line supported preferred. Knowledge of regulatory compliance and reimbursement methodologies preferred. Encoder experience preferred Training and education skills preferred. PHYSICAL DEMANDS This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.
PURPOSE OF THIS POSITION The primary purpose of the Professional Coding Integrity Specialist (PCIS) is to review, enter and/or modify charges as appropriate, including review of clinical documentation to ensure charge is supported and/or to determine specific charge/modifier assignments, for designated clinical areas. JOB DUTIES/RESPONSIBILITIES Duty 1: Review, enter and/or modify charge on encounters to ensure accurate and compliant and optimal charge capture in a time-sensitive manner for designated clinical service lines. Review clinical documentation to ensure charge is appropriately supported and/or to determine the assignment of the accurate charge, modifier, E&M levels, etc. Assign ICD-10 diagnosis codes as appropriate. Work "exception" accounts (e.g. canceled accounts, combined, unique modifier or charge rules requiring review, etc.) through review of clinical documentation and/or collaboration with appropriate resources, as needed, to resolve. Duty 2: Support resolution of claim-scrubber edits (Quadax) resulting from charges entered by the Revenue Integrity Validation team; collaborate with clinical areas, coding, PFS, etc. to support resolution of edits; trend, identify opportunities, and collaborate with RI Educator and/or Claims Resolution Specialist to avoid/reduce future edits. Support Condition 44 notifications (inpatient to observation status) process by properly modifying charges and calculating hours etc. Duty 3: Track and quantify revenue impact to organization as a result of charge corrections made, including impacts from modifications to processes. Duty 4: Identify opportunities related to clinical documentation and/or other system enhancements to support optimal and accurate charge processes; collaborate with CDI Specialist, Claims Resolution Specialist, Revenue Integrity Auditor, Revenue Integrity Educator, clinical area, and other areas to support resolution of issues. Duty 5. Demonstrate proficient knowledge of federal, state and third party charging guidelines of clinical areas supported by the Revenue Integrity Validation team to ensure optimal, accurate and compliant charging. Understand changes to applicable coding and billing regulations, including annual IPPS/OPPS revisions, by resourcing credible references (i.e. CMS website, Craneware, publications, professional contacts, reliable internet sources, seminars, etc.). Collaborate with clinical areas, Revenue Integrity Team, Coding Integrity Team and/or other impacted areas to support implementation of changes. Duty 6: Participates in system testing as a result of upgrades, changes, enhancements, new application implementations, etc. that may impact Revenue Integrity Validation processes. Duty 7: Regularly attends and actively participates in in-services, organizational and department meetings and continuing education programs as offered in order to remain current with organizational and industry changes and best practice. Communicate and disseminate information to other departments as applicable. REQUIRED QUALIFICATIONS An Associate's degree in a related field including, but not limited to, health information, business or related clinical profession preferred or 1-2 years' experience from which comparable knowledge and abilities have been acquired. Coding certification (CCA or CPC) required or obtained with 9 months of hire date Knowledge of medical terminology and anatomy and physiology required. Knowledge of CPT/HCPCS/APC coding systems, appropriate use of applying modifiers, CPT Assistant, LCD/NCD and ICD-10 required. Ability to research, review and interpret Federal, State and Local billing regulations required. Familiarity with utilization of computers and commonly used applications, including Microsoft Office Suite, (Windows, Excel, Word, Outlook), electronic health record, internet required. Ability to track and monitor data to identify trends pertaining to charge issues. Excellent organizational, time management and problem-solving skills required; detail oriented and follow through. Positive service-oriented interpersonal and communication (written and verbal) skills required. PREFERRED QUALIFICATIONS Other certifications applicable to primary clinical service line supported preferred. Knowledge of regulatory compliance and reimbursement methodologies preferred. Encoder experience preferred Training and education skills preferred. PHYSICAL DEMANDS This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.
St. Luke's University Health Network
Allentown, Pennsylvania
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors. Assures that the most accurate and descriptive codes from the AHA ICD-9-CM/ICD-10-CM/PCS diagnoses and/or procedures support the services/treatment rendered. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy. Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement. Work with the physician liaison in review of patient medical records identified by RAC/MIC/CGI/QIO and other outside auditors in retrospective reviews for DRG and coding-related issues. May participate in review of other medical necessity issues as needed. Develop and apply appeal arguments to defend the coding of and by the coding professionals and be able to refute the coding determination made by the outside payor including but not limited to CMS, Aetna, IBC, Omniclaim, QIP, Gateway Health, etc. Draft appeal letters, including the coding argument, to support network coding. Identify clinical documentation improvement issues and through excellent communication with physicians, nurses, coding and other members of the health care team and work independently to resolve such issues. Participate as needed in Administrative Law Judge (ALJ) hearings. Spends approximately 20% of their time weekly coding/abstracting patient medical records according to ICD-10-CM/PCS, UHDDS and CMS guidelines. Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes, and MS-DRG assignment. Performs data entry of coded patient medical records into EPIC, maintaining a 95% coding accuracy rate as measured through quality reviews. Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment. PHYSICAL/SENSORY DEMANDS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: RHIA, RHIT and/or CCS with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment. Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required. TRAINING, KNOWLEDGE AND EXPERIENCE: Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting. Knowledge of anatomy and physiology, pathophysiology, and medical terminology required. Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred. Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity. Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's St. Luke's University Health Network is an Equal Opportunity Employer.
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors. Assures that the most accurate and descriptive codes from the AHA ICD-9-CM/ICD-10-CM/PCS diagnoses and/or procedures support the services/treatment rendered. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy. Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement. Work with the physician liaison in review of patient medical records identified by RAC/MIC/CGI/QIO and other outside auditors in retrospective reviews for DRG and coding-related issues. May participate in review of other medical necessity issues as needed. Develop and apply appeal arguments to defend the coding of and by the coding professionals and be able to refute the coding determination made by the outside payor including but not limited to CMS, Aetna, IBC, Omniclaim, QIP, Gateway Health, etc. Draft appeal letters, including the coding argument, to support network coding. Identify clinical documentation improvement issues and through excellent communication with physicians, nurses, coding and other members of the health care team and work independently to resolve such issues. Participate as needed in Administrative Law Judge (ALJ) hearings. Spends approximately 20% of their time weekly coding/abstracting patient medical records according to ICD-10-CM/PCS, UHDDS and CMS guidelines. Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes, and MS-DRG assignment. Performs data entry of coded patient medical records into EPIC, maintaining a 95% coding accuracy rate as measured through quality reviews. Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment. PHYSICAL/SENSORY DEMANDS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: RHIA, RHIT and/or CCS with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment. Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required. TRAINING, KNOWLEDGE AND EXPERIENCE: Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting. Knowledge of anatomy and physiology, pathophysiology, and medical terminology required. Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred. Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity. Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's St. Luke's University Health Network is an Equal Opportunity Employer.