Summary

SUMMARY: Responsible for completing provider education and training to increase and strengthen health care providers' awareness and understanding on a variety of compliance-related topics, including medical record documentation guidelines and coding principles; develops and disseminates educational reference guides, cheat sheets, and advisories.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification. 

1.  Proficiency Level Analyzes and assesses risks with billing and coding rules and regulations based on CMS, OIG Work plan, Medi-Cal program guidelines, Industry Experts, etc.; analyzes inpatient and outpatient data and reviews patterns and trends to identify potential risk areas.

2.  Evaluates the quality of clinical documentation and monitors the appropriateness through physician education and feedback and achieve accurate coding to support the optimal allowable reimbursement.

3.  Partners with System Management (Revenue Cycle, HIM, Case Management, Quality, etc.) in support of developing standardized documentation, medical necessity, coding and billing policies and guidelines, and other educational materials.

4.  Performs other duties as required.

5.  Performs inpatient and outpatient coding audits, investigations, inquiries and correspondence as needed from key stakeholders; performs inpatient or outpatient coding related audits and reviews.

6.  Prepares and composes all findings and recommendations in a summary report and facilitates communication to the key stakeholders.

7.  Reviews the electronic health record to identify potential coding & billing compliance issues, based on CPT-4, HCPCS, ICD-10-CM/PCS coding rules, AHA Coding Clinics, Medicare conditions of payments (NCD/LCDs), Medicare Benefits and Claims Manual; performs quality reviews on medical records by validating assignment accuracy of E/M coding rules, CPT-4 and HCPCS codes, and ICD-10-CM/PCS.

MINIMUM QUALIFICATIONS:
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Preferred Education: Bachelor’s Degree in related field. Preferred Experience: Experience training physicians.

Required Education: High School diploma or equivalent.

Required Experience: Five years of direct coding, compliance, and auditing experience. Five year of.In patient or Outpatient coding and documentation auditing or active coding experience in the following E/M coding rules, CPT-4, HCPCS, ICD-10-CM/PCS.

Required Licenses/Certifications: AAPC Certified Professional Coder (CPC) or AHIMA’s Certified Coding Specialist (CCS-P) or Certified Documentation Improvement Practitioner (CDIP).