Certified Coder Responsibilities:|
The incumbent assigns and sequences ICD-9-CM/CPT codes to diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
Abstracts all necessary information and assigns codes (ICD-9, CPT ), which most accurately describe each documented diagnosis, surgical procedure and special therapy or procedure according to established guidelines.
The incumbent determines the final diagnoses and procedures stated by the physician or other health care providers are valid and complete.
Quantitative analysis - Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
Qualitative analysis - Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.
Analyzes provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.
EDUCATION AND EXPERIENCE:
Completion of high school, or equivalent. Two years of coding experience using ICD-9-CM or equivalency. CCS, CCS-P or CPC certification is required. The incumbent is expected to enroll in continuing education courses to maintain certification. Six to twelve months would be required to become proficient in most phases of the job.
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-9-CM, Volumes 1- 3, CPT coding conventions.
Skill in correlating generalized observations/symptoms (vital signs, lab results, medications, etc.) to a stated diagnosis to assign the correct ICD-9-CM code.
Advance knowledge of medical codes involving selection of most accurate and descriptive code using the CPT codes for billing of third party resources.
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 Electronic Health Record in order to analyze encounters and notify providers of data that needs corrections through EHR broadcasts, notifications and templates.
Must have good math skills and effective communication skills. Must be knowledgeable of the fiscal requirements, policies, and procedures of federal, state, and tribal programs. Requires the knowledge of the business use of computer hardware and software to ensure the effectiveness and quality of the processing and presentation of data. Requires skill in the use of a wide variety of office equipment including: computer, typewriter, calculator, facsimile, copy machine, and other office equipment as required. Must be able to follow instructions and work independently.
COMPLEXITY OF DUTIES:
Duties are highly complex, varied, require planning and coordinating several activities at one time, and demand the use of problem solving skills and analysis of circumstances to develop appropriate actions. Is subject to frequent interruptions, in person and by phone, which require varied response.
Works under the general direction of the CFO. Has latitude for the exercise of initiatives, discretion, and independent judgment.
RESPONSIBILITY FOR ACCURACY:
Review of work and subsequent procedures would detect most significant errors of job functions. However, more serious errors could result in inefficient operations and loss of revenue.
Because information in the health record is the basis for reimbursement as well as clinical decision-making, coding entries must be complete and accurate. The amount of reimbursement depends on the correct coding of diagnoses and procedures and appropriate DRG/APC assignment. The work has a direct effect on medical record keeping and a direct impact on the accuracy, documentation, timeliness, reliability and acceptability of information in the medical record services.
Work has considerable impact on the accreditation status of the clinic, quality of patient care, reliability of research data, compliance and the maximization of Third-Party reimbursement.
The coding function is a primary source used in health care today, and promotes provider/patient continuity, accurate data, statistic information, and the ability to optimize reimbursement.
CONTACTS WITH OTHERS:
Internal contacts occur on a regular basis with departmental personnel. External contacts include clients, families, health professionals, and general population, as well as other entities. Purpose for contacts is for the exchange of information and requires tact, courtesy, and professional decorum. Contacts are with agencies both federal and state including: Medicaid, Medicare, and other private insurance companies. Requires the ability to organize work and deal effectively with the public and federal, state agencies.
Has access to all departmental files, memos, financial records and health records, which are considered confidential. Must adhere to all confidentiality policies and procedures in the performance of duties.
Concentration varies depending on the tasks at hand. High levels of mental concentration are required. Must handle multiple tasks simultaneously and is subject to interruptions. Physical effort requires sitting and reaching with hands and arms. Manual dexterity, visual acuity, and the ability to speak and hear are required.
Work is performed in normal business office environment, with occasional travel required.
Credentialing Coordinator Responsibilities:
Coordinate and perform oversight of Credentialing and Re-Credentialing activities in compliance with federal, state and NCQA requirements and guidelines.
Act as facilitator for all credentialing and re-credentialing activities.
ESSENTIAL JOB RESULTS:
Perform oversight of all credentialing and re-credentialing activities and processes including development of policies, procedures, workflows and tools.
Oversight of the contracted Credentialing Verification Organization (CVO).
Coordinates and conducts initial, annual and focus credentialing delegation audits.
Participates in and reports credentialing activities to quality committee meetings.
Assists and participates in regulatory audits, including preparation of any corrective action plans.
Responsible for orientation of any new specialists and acts as a resource to support the team.
Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
Contributes to team effort by accomplishing related results as needed.
Bachelor's degree in Health Care, Business or related field or equivalent work experience.
Comprehensive knowledge of Federal, State and NCQA requirements and guidelines.
3 - 4 years of relevant credentialing experience.
Proficient in MS Office.
Excellent writing skills and the ability to express ideas concisely and clearly orally and in writing.
Able to multitask, work independently and with minimal supervision.
Able to appropriately maintain confidentiality.
CONDITIONS OF WORK:
Office Hours: Monday-Friday, 8am to 5pm.
Reviews, analyzes, and codes diagnostic and procedural information that determines Medicare, Medicaid and private insurance payments. The primary function of this position is to perform ICD-9-CM, CPT and HCPCS coding for reimbursement. The coding function is a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement. The coding function also ensures compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines.