Under general supervision, reviews and analyzes diagnostic and procedural information to ensure compliance with established coding guidelines, policies, regulations and accreditation guidelines necessary for the maintenance of accurate Electronic Health Records (EHR) for database information and optimal reimbursement with Medicare, Medicaid, Private Insurance and any other third party payer. Responsible for the accurate and timely preparation and submission of claims to third party payers, intermediaries, and responsible parties including rebilling and corrected billing of accounts previously submitted.
Supervised by the Health Center Business Manager
Major Duties and Responsibilities
- Performs a comprehensive review of the visit to assure the presence of all necessary components of patient and record identification, signatures and dates of service and other necessary data is present and consistent with the nature of the treatment rendered.
- Compares all relative information and assigns appropriate ICD, CPT or HCPCS codes which most accurately describe each documented diagnosis, procedure or therapy according to established billable charges guidelines.
- Assigns and sequences codes to diagnosis and procedures for documented information. Analyzes and abstracts information from the medical record to identify secondary complications and co-morbid conditions to assure appropriate assignment under the Diagnostic Related Group (DRG), Ambulatory Patient Classification (APC) systems and other alternate resources.
- Ensures the final diagnoses and operative procedures as stated by the physician or other health care providers provider are valid and complete.
- Ensures that the medico-legal requirements of the record are complete, accurate, and reflects sufficient data to justify the diagnosis and warrant treatment and end results.
- Identifies inconsistencies, discrepancies and/or trends within the medical record and discusses with the appropriate medical, nursing, or healthcare providers, and recommends appropriate modifications to include medical necessity under the Correct Coding Initiative.
- Provides ongoing education, updates and briefings for the medical staff, business office staff, and other health care providers on changing coding conventions, rules, regulations and guidelines.
- Approves complete visits for billing and sends notifications to the provider when information is missing, conflicting or incomplete in the coding queue.
- Maintains updated website newsletter subscriptions for all related payers for current coding requirements.
- Compiles provider activity report on a weekly basis.
- Maintains the privacy and confidentiality of patient information in accordance to the Privacy Act, Health Insurance Portability and Accountability Act (HIPPA), Electronic Health Record (E.H.R.) system policies and procedures.
- Responsible for maintenance and control of unbilled claims. Reviews system generated reports daily to identify claims that are ready for billing in alignment with established reimbursement guidelines and screening criteria by specialty.
- Responsible for the error correction for all rejected/suspended claims previously submitted to third party payers. Notifies supervisor of all claims deemed unbillable, along with the reason(s).
- Batches payments and reconciles against bank statements.
- Responsible for self-education by reading all third party newsletters, periodicals and updates circulated by management. Attending all continuing education opportunities including webinars when made available.
- Performs audits in accordance with the facility Quality Assurance and Improvement study designs, which may include findings from provider documentation trends, coding peer reviews, and reimbursement denials. Provides reports of findings and feedback to parties involved.
- Performs special projects and other related duties as assigned.
Secondary Duties and Responsibilities
Primary back up support when Purchased Referred Care Case Manager is unavailable.
Knowledge, Skills and Abilities
- Advance knowledge of medical terminology, abbreviations, techniques and surgical procedures; anatomy and physiology; major disease processes; pharmacology; and the metric system to identify specific clinical findings to support existing diagnoses or substantiate listing additional diagnoses in the medical record.
- Advance knowledge of medical codes involving selections of most accurate and description code using the ICD-CM/CPT/HCPCS code for all funding services.
- Extensive knowledge of official coding conventions and rules established by the American Medical Association (AMA), and the Center for Medicare and Medicaid Services (CMS) for assignment of diagnostic and procedural codes.
- Knowledge of RPMS and ISH Electronic Health Record in order to analyze encounters and notify providers of data that needs corrections through EHR broadcasts, notifications and templates.
- Must have excellent math skills and effective communication skills.
- Must be knowledgeable of the fiscal requirements, policies, and procedures of federal, state and tribal programs.
- Requires skill in the use of all office equipment, hardware and software.
- Duties are highly complex, varied and require planning, coordinating several activities at one time; demand the use of problem solving skills and effective time management.
Minimum Qualifications, Education and Experience
- High School Diploma, GED certification or equivalent
- Three (3) years coding experience using ICD-9-CM/CPT/HCPCS or equivalency and one (1) year billing experience.
- The following license and/or certifications are required prior to employment start date:
- Certified Coding Specialist (CCS), Certified Coding Specialist – Physician Based (CCS-P) or Certified Professional Coder (CPC) certification
- CPR certification
- Knowledge of RPMS and IHS electronic health record
- Must be able to successfully pass a stringent background and character investigation in compliance with PL 101.630.
- Will require a post-offer, pre-employment and random drug screening.
- Work is performed indoors.
- Work hours are 8:00 am to 5:00 pm Monday through Friday with some overtime and evening meetings required.
- Subject to hazardous materials which may cause bodily harm: smoke, common colds, influenza, dust, odors and elevated noise levels.
- Tasks may be performed on uneven, inclined, hard and soft carpeted floors, cement structures and surfaces.
- Duties may involve walking, standing for long periods of time, sitting and crouching.
- Specific required movements include the following:
- Trunk: bend, twist, rotate, push, pull, and carry.
- Arms: reach, carry, push, pull, lift, twist, rotate
- Legs: lift, push, pull, twist, rotate
- Hands: grasp, manipulate, bilateral coordination, eye and hand coordination, overall and finger dexterity.
Salary: $20.03 – $27.04 Per Hour
All applicants must be able to demonstrate their US work authorization during the employment verification process.