Required Education and Experience:High School diploma or equivalent and a minimum of 5 years coding/healthcare reimbursement experience. Certification by American Academy of Professional Coders (CPC) for a minimum of 5 years or equivalent organization and CRC (Certified Risk Coder). CRC certification must be obtained within 6 months. Must have advanced knowledge in medical terminology and anatomy. Must have advanced knowledge of insurance reimbursement, principles and practice. Must have knowledge of computer and Microsoft Office.
Summary/Objective:Conduct Medical Compliance Review of Clinic providers for inpatient and outpatient claims.
Conducts chart reviews of medical records for outpatient/inpatient providers. Reports on documentation to support CPT, ICD10, HCPCS and RAF reviews.
Provides timely provider communication by memo and telephone. Identifies deficiencies and educational needs of provider. Reports clear and detailed recommendations to improve documentation of level of service billed specificity of ICD10 codes and RAF scores.
Determines the level of inservice education needed for providers. Communicates credible and concise findings in provider reports. Presents in a professional, organized and positive manner.
Demonstrates a contribution to the department�s operation and goals/targets for the year. Maintains monthly log of activity, Completes a minimum of 10 charts/quarter for assigned providers. Prioritizes workload maintains control over interruptions.
Demonstrates ability to use auditing software program, IDX system, LCD and local hospital resources to conduct reviews and summary of findings. Ability to use the TES program in IDX for retrospective or concurrent reviews. Pursues medical records needed from outside resources (i.e. SNF, other hospitals)
Identifies departmental process discrepancies during review process. Compiles monthly documentation of keying errors by provider, DOS, MRN and batch number. Reports any operational areas of risks identified. Reports treatment inconsistencies for review.
Adheres to guidelines set by the clinic�s Compliance Program and Audit policy and procedures