General Description of the Job Class

Coordinate /review the work of vendor outsourcing partners and assist with the training and continuing education programs. Code medical records utilizing ICD-9-CM/ICD-10-CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures, and appropriate/optimal reimbursement professional charges. Abstract information from medical records following established methods and procedures. 

Duties and Responsibilities of this Level

·         Ensure quality and quantity of work performed through regular audits and QC for vendor services for various HB and PB coding processes, including edits, denials, and charge capture.

·         Monitor and track outsourcing vendor performance as it pertains to QC and Productivity

Review and research the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT, HCPCS coding conventions, and payer-specific coding guidelines.

·         Develop and assist with training, presentations, and educational tools for any relevant topic as it relates to continuing education programs on areas of specialization, coding, operational workflow, and quality control.

·         Collaborates with other departments and partners (e.g., Revenue Integrity, QA Team, Compliance Specialist, Internal Controls, Billing and Collections, and Revenue Managers) to ensure coding feedback to outsourcing vendors and the team is provided.

·         Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.

·         Consult with and provide feedback to physicians or the department on coding practices and conventions to provide detailed coding information. Communicate with clinical, ancillary staff, and revenue managers for needed documentation to ensure accurate coding.

·         Develop and maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT-4 coding guidelines to inpatient/outpatient diagnoses and procedures.

·         Develop and maintain a thorough understanding of medical record practices, standards, regulations, Health Care/Finance Administration (HCFA), and Uniform Billing (UB-04), CMS, and other payer policies, and any healthcare relevant changes.

·         Develop and maintain a thorough understanding of payer-specific guidelines as they pertain to edit review and validations

·         Develop and maintain a thorough understanding of payer-specific billing and coding requirements

·         Develop and maintain a thought understanding of CMS and the Palmetto Claim Processing Manual, including claim rejections.

·         Ensure active participation in any team event and departmental activities in the PRMO and DUHS

·         Ensure compliance with PRMO and DUHS policies and code of conduct

·         Assist with special projects as required

Medical Records Coder II -  Vendor Support - HB Edits

This is a progressive coder/auditor position, with opportunity for development and growth, accountable for key strategic vendor education and ensuring coding accuracy for the vendor services.  The ideal candidate has experience and knowledge in coding/billing, denials, payer guidelines, as well as well-developed analytical skills in this area.  The position is a forward-facing role that will have regular access / and communication to our coding vendor partners.  Coding certification is required d and additional certification for auditing is preferred.

• Quality Control - (40%)
  • Review of vendor work to identify erroneous coding patterns and errors
  • Review of vendor work to identify incorrect coding decisions and system actions
  • Review of vendor work to assess overall quality eff ectiveness including identifying areas of opportunity to ensure sy stem enhancement and workflow improvement
  • Providing feedback and education to vendor services to address issues found in the QC process
  • Monitoring and tracking of QC results
  • Provide coding process analysis and support for the department as an expert for the Outsourcing partner QC team and supervisor
  • Vendor Education (30%)

 Plan activities aimed at improving the Coding Vendor's quality performance in operations

o    Design and implement strategies for enhancing vendors' work quality and increasing productivity.

o   Evaluate the effectiveness of the improvement strategy through sustained tracking and monitoring of vendors' related WQ.

o Reporting of vendor-specific trends and issues to upper management

Coding 30%

Performing actual coding function on various coding WQs in PB and HB edits and denials

o   Performing necessary research and investigation to resolve coding-related issues and enhancing the business process associated with job functions and responsibilities

o   Maintaining coding skills by continuing education and keeping abreast of regulatory healthcare-related changes and payers' guidelines

Required Qualifications at this Level

Education:

High school graduate, a Bachelor's is preferred

Experience :

Minimum of 2 years work experience in Coding a nd/or Auditing  experience

Degrees, Licensure, and/or Certification:

 CPC, CPC-P, CCS, CCS-P, CPMA

Knowledge, Skills, and Abilities:

Effective written and verbal communication skills

Ability to communicate with customers/staff with diverse educational backgrounds

Ability to provide feedback and education in a group setting or over WebEx

Analysis of data and processes for opportunities for improvement

Attention to detail and accuracy

Computer literacy

Distinguishing Characteristics of this Level

Be able to teach coding effectively to a diverse audience.

This job description intends to provide a representative a nd level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any par ticular position. Employees may be directed to perform job-related tasks other than those specifically presented inthis description.