Summary
 

Reviews medical documentation to perform a variety of coding validations for multiple lines of business under Medicare to determine accuracy of billing and payment. Reassigns and sequences diagnostic and procedural codes using universally recognized coding system as appropriate. Compiles and analyzes statistics to determine focus areas for targeted medical review activities where there is the greatest potential for inappropriate Medicare payments.

Description
 

Logistics:

• Work hours will be 8:00 am to 5:00 pm Monday through Friday.

• Work from home position. You must have high-speed (non-satellite) internet service and a private home office to work from home.

What You’ll Do:

• Determines methodology to identify cases for DRG, HIPPS, HCPCS, RUG, and APC validation. Conducts targeted coding, documentation reviews, and validation reviews coordinating rate adjustments and adjudication of corresponding claims. Utilizes Grouper, Rover, MDS QC tool or other appropriate software for code validation.

• Compiles/analyzes statistics to determine focus areas for targeted medical review activities where there is the greatest potential for inappropriate Medicare/TRICARE payments demonstrating records reviewed, outcomes, trends, and savings. Notes deficiencies and makes recommendations to management and others as appropriate/requested. May complete appropriate paperwork/documentation regarding claim/encounter information to correct deficiencies.

• Provides coding guidance to clinical review staff. Develops necessary training or reference materials for review staff.

• Consults with appeals, provider outreach and education and other supported areas of division as needed as a resource for medical records and coding issues.

To Qualify for This Position, You’ll Need:

• Required Licenses and Certificates: Certified Coding Specialist (CCS) OR Certified Professional Coder (CPC) OR Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)

• Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing or successful completion of examination offered by American Health Information Management Association (AHIMA) or Academy of Professional Coders (AAPC)

• Required Work Experience: One year either ICD-9, DRG, APC, HIPPS, HCPCS, or RUG coding and validation; OR two years: one-year clinical experience and one-year in either DRG, APC, HIPPS, HCPCS, or RUG coding and validation.

• Required Skills and Abilities: Working knowledge of word processing software. Knowledge/understanding of medical terminology and medical coding. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.

• Required Software and Tools: Microsoft Office.

We Prefer That You Have:

• Work Experience: Two years of medical coding experience.

• Education: Associate Degree in Nursing or bachelor's degree in health information management.

• Software and Tools: Ability to navigate between multiple windows-based programs.  Intermediate experience with Excel, Outlook, Access and word processing programs.

• Preferred skills: Knowledge of CMS guidelines and Medicare Part B.