BrightSpring Health Services

The Clinical Coding and Audit Specialist monitors, responds and performs the clinical coding and audit support required to ensure timely processing of all episodes of care. Reviews documentation for appeals processes across the Home Health enterprise for all payor types striving to improve clinical documentation and minimize lost revenue. Conducts analysis on timely submission of coding reviews and supports branches to prevent edit lock OASIS to be prior to the 30-day limit. Provide support and coordination with branches if re-coding records is required for sufficient billing practices to be met. This position will also support detailed level reporting and analytics, clinical appeals, root cause analysis, and address identified trends in reasons for denials related to coding and/or OASIS related documentation. Partners with Home Health operations and customers to drive improvement in the quality of services delivered to patients.

Code diagnosis accurately utilizing ICD-10 for purposes of reimbursement and compliance within coding regulations and guidelines
• Identify problems and follow up as needed with appropriate staff and/or department for correction
• Review coding to ensure documentation is completed within Agency's admission timeframe
• Establishes and promotes ongoing communications with Agency personnel
• Charged with responding, managing, and monitoring payer Additional Documentation Requests (ADR) and communications. Works with branch staff to gather required information and submits timely response to ADR requests
• Monitors OASIS timing and collaborates with branch and billing staff to determine resolutions
• Audits patient records for quality and compliance per applicable home health regulations for submission for pre-claim review process of Review Choice Demonstration and/or Targeted Probe and Educate records
• Audits patient records for quality and compliance per applicable home health/hospice requirements or for other projects per agency need including but not limited to improvement plans as part of targeted probe and educate surveys, performance improvement programs and patient safety surveys
• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence-based medicine, local and national medical management standards, and protocols
• Performs ad hoc audits and reporting per request
• Analyzes information gathered by audits and reports and makes recommendations for changes to or development of policy/process and education
• Tracks audit result reporting results and shares with all interested stakeholders (e.g., compliance, legal, clinical support, and local operations & clinical staff)
• Acts as a resource and has expert knowledge of Medicare, Medicaid, ICD-10 Coding and OASIS and other applicable regulatory requirements
• Provides consultation and education for clinical staff as needed to ensure accurate, timely, compliant documentation that drives accurate billing

• Clinical review positions will require a RN degree in nursing from an accredited or approved school
• Two years of experience in health care utilization review or home health care
• Clinical review will require a current license/registration by state of hire as a nurse
• Successfully completed HCS-D coding certification, required and to be maintained
• Successful achieve of OASIS certification, required to be maintained
• Expert written and verbal communication skills
• Strong presentation skills to various audiences
• Strong interpersonal skills
• A thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirements
• Extensive knowledge of Home Health or Hospice operations, compliance requirements
• Extensive experience in working with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC responses
• Ability to prioritize tasks and manage multiple projects
• Strong analytical and problem-solving skills with attention to detail
• Ability to utilize a personal computer and other office equipment
• Proficient use of Electronic Medical Record software
• Proficient use of Microsoft Office Suite-Excel, Word, and PowerPoint
• Solid ability to learn new technologies and possess the technical aptitude required to understand flow for data through systems as well as system interaction