Coding and Reimbursement Specialist

Job Description

The Coding and Reimbursement Specialist, CCS is responsible for coding and abstracting thoroughly, clinical data from the medical record.This includes both inpatient, outpatient, commercial, Medicare, Medicaid, and Illinois Public Aid, plus any other payor types. This accurate and timely coding is essential for reimbursement to the hospital, according to the appropriately selected principal diagnosis, grouped to the DRG in accordance with rules and regulations and coding methodologies, resulting in reimbursement and billing compliances as set forth by the Office of Inspector General. Manages workload and assigns work to three inpatient and two outpatient coders and oversees the day to day workings of the coding/reimbursement area. Monitors various regulatory sources to keep HIM coding and other staff informed and trained on various coding rules, regulations and related issues. Works closely with patient financial services to resolve any claim denials. Assists in updating the charge master. Educates physician staff on documentation requirements to support E/M codes assigned to claims. Periodically audits the accuracy of all coding, including physician E/M, compared to the documentation in the record.Participates in various medical center billing, coding and compliance related groups. Works closely with physicians to document and interpret documentation and care of the patient. Works with Director in hiring and firing and evaluation of the coding staff. Has input into systems and change of processes to maintain a current status. This position is directly related to thereimbursement the institute receives through skill, accuracy and keen job knowledge. This position must be proficient in CPT, ICD-9-CM, E/M coding methodologies and the DRG and APCreimbursement system. Is accountable for particular components in maintaining an accounts receivable in the 50s. Must be able to work well with physicians and patient care staff to guide and provide reimbursement information in accordance with compliance. This position must be able to teach, train, and work with various coding systems. This position must be able to write and express ideas well in updating manuals both procedure and compliance with input from Director. Requires self motivation, adaption to intense work situations, ability to work well with others or alone. Strives for excellence and has demonstrable work ethic.

Other Skills and/or Knowledge Required: Proficient in CPT, ICD-9-CM, E/M coding methodologies and the DRG and APC reimbursement system. This position must be able to teach, train, and work with various coding systems.

Codes diagnoses and procedures ICD-9-CM, CPT, E/M coding methodologies. - Is extremely proficient in all areas of coding and coding compliance and processes. Is able to code proficiently all types of patient records according to payor, Medicare, Commercial, Medicaid, Illinois Public Aid and any and all payor types. Carefully sequences principal and secondary diagnoses for appropriate and compliant reimbursement. The record is thoroughly reviewed for documentation, test interpretations, coded and processed using the computer software in the encoder for determination of the most appropriate and compliant reimbursement. This is done according to the rules and regulations and guidelines of payors such as Medicare, Medicaid, etc. The Office of Inspector General has determined overall DRG or diagnosis specific focus. This position must be thoroughly knowledgeable in coding compliance and methodologies. Must maintain a current status in workload. Finished work compliant and accurate.

APC reimbursement system - Monitor systems and processes and is knowledgeable with APCreimbursement system. Works with the IS, business office and HIM staff, along with ancillary departments to facilitate information needed for coding and billing appropriately. This position works very closely with the medical staff, the Vice President of Medical Affairs, the Emergency Room Physicians, Medical Director and Director supporting their need for more thorough documentation and a better understanding of the coding policies and methodologies as it relates to their diagnoses.

Process payor record - Maintains daily interaction with coding staff to help process all types of payor record. Completes and works with evaluations, interviews, hiring, discipline, terminations, staff development through inservice, seminars and meetings. Attends continuing education to keep abreast of upcoming changes in regulations. Responsible for accounts not selected for billing list, inpatient, outpatient and miscellaneous for follow through, which involves retrieval, physician interaction. This is in concert with benchmarking from the HARA report, meeting deadlines and identified goals. Works closely with business office assistant managers and staff to maintain communications for timely billing and payment. This includes prompt and accurate information on the UB. Maintains a current workload status.

Compliance - Responsible for self and staff compliance with government regulations, guidelines, facility policy and procedure and coding compliance in itself as it relates to compliant coding for compliant billing. Works as a liaison with assistant managers, business office and patient account representatives. Works closely with data analysis on DRG/APC projects and information gathering.

Informing Director - Keeps director updated on any important matters and potential problems. Leads and mentors by example. Writes and updates procedure manuals completely listing and updating educational sources for coding guidelines and selection of principal diagnoses.

ER evaluation and management coding - Works with experience and expertise in Emergency Room evaluation and management coding. Works with physicians for appropriate documentation, completeness of record in the PICIS system. Generates productivity and quality reports. Responsible for quarterly audits of each coding function and coder/abstractor, inpatient. Review of HCFA rules and regulations, guidelines, facility policy with coding/billing staff pertaining to updates or current practice. Internal compliance and audits, noncoding issues for education with staff.

Selects appropriate assignments for coding/abstracting from work queue. - Uses the encoder, ICD-9-CM and CPT-5 coding systems to accurately code diagnosis and procedures for all inpatient, outpatient surgery, observation, ER, and other outpatient encounters. Abstracts designated statistical data from patient record and enters the information into the abstract database. Contacts physician and/or ancillary departments when additional information is needed to accurately code the record. Strives to decrease pending accounts on all patient types. Assists in preparing data reports for other departments as requested. Selection/sequencing of principal and secondary diagnosis done correctly at least 98% of the time. Abstracts all appropriate data at least 97% of the time. Writes completed record to appropriate queue at least 100% of the time, or reassigns to other group work queues if required. Meets minimum standard productivity requirements as outlined in coding productivity policy. Correctly logs out of the EPF system at least 100% of the time.

Qualifications

CCS Certification.

3+ years of recent hospital based coding in all systems.

Additional Information

Job Status: Full Time 

Eligibility: EAD GC/ GC/ US Citizen

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Contact:  703 349 1214

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