In a multi-specialty practice, conducts audits of all commercial carrier claims to ensure correct diagnosis, procedure, and modifier usage. Provides coding related education and support to expedite charge entry process. Proactively appeals and assists with re-billing of commercial carrier claims addressing identified errors or edits. Identifies and reports trends regarding provider documentation leading to denials and reimbursement issues. Duties: 1. Reviews patients' medical records to ensure coding levels and charting meets standards and regulations.
2. Capable of performing retro audits on patients' account to ensure documentation supported the level of Evaluation and Management charged.
3. Completes analysis, charts, and spreadsheets to present outcomes to physicians.
4. Educates physicians and employees on compliance audit findings by specialty after routine audits or when problems are identified.
5. Responsible for being up-to-date and knowledgeable of coding process and diagnostic procedures as well as carrier specific policies, guidelines, and updates. Researches contract allowables to ensure proper payment as well as remaining current about federal and state legislative changes that affect outcomes.
6. Share information as necessary with the Coding & Insurance departments. Stay informed of updates on payer websites.
7. Communicate with Coding and Insurance Supervisors regarding denial trends, problematic denials and reimbursement issues. Inform Regulatory Services Manager of CPT codes that are routinely not paid, repetitive noncovered diagnoses, or codes not paying according to contractual fee schedules.
8. Reports all identified compliance audit issues to Regulatory Services Manager.
9. Assist Coding and Insurance/Billing departments with third party payer coding rules and regulation questions.
10. Provide coding related support to the Coding Department and also to Insurance and Billing Department for follow-up to expedite appeals and re-billing of claims. This will include researching and correcting claims in order to validate denial adjustments. Communicates closely with the Insurance Department Medicare Team to ensure that secondary claims are not held up due to coding issues.
11. Provide other assistance to the Coding and/or Insurance and Billing Department as directed by the Regulatory Services Manager.
12. Maintains patient confidentiality.
13. Attends meetings when required.
This job description in no way states or implies that these are the only duties to be performed by this employee. He or she will be required to follow other instructions and to perform any other duties requested by his or her supervisor.
Qualifications: Minimum of Health Information Technology degree (A.A.S.) with R.H.I.T. or R.H.I.A. certification and 3-5 years of multi-specialty coding experience and claims management, or CCS-P or CCS certification with 4-6 years experience.
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