Responsible for researching and analyzing coding related pre-bill scrubber edits , denials, and requests for review from Patient Financial services , and ensuring proper coding in compliance with government and third party payer regulations and CPT-4 , ICD, and HCPCs guidelines. Responsible to appeal denials and follow up with payers until the denied claims are paid. Collaborates with multiple departments and participates in review of Recovery Audit Contractor and other government audits and appeals. Provides reports to Coding Resources Advisors for trending and research and clarification of coding (ICD, CPT- 4/HCPCS) and abstracting of diseases and surgical procedures. Provides education to the Coding Resources teams based on findings .Ensures adherence to all applicable Billings Clinic and regulatory compliance policies and procedures governing medical records coding, insurance billing and reimbursement methodologies.
Essential Job Functions
• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct, and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental, and outside agency standards as it relates to the environment, employee, patient safety, or job performance.
• Researches, analyzes, and appeals government and third-party payer coding-related denials of service based on explanation of benefits and remittance advice information and/or patient requests.
Appeals denials and follow up with payers until the denied claims are paid. Escalates high complexity issues to the Coding Resources Advisors. Revises and recodes claims as appropriate to maximize reimbursement.
Maintains a detailed knowledge of and ensures adherence to all applicable Billings Clinic and regulatory compliance policies/procedures governing medical record coding, insurance billing, and reimbursement methodologies in all aspects of the job. Actively seeks out clarification and/or updated information to ensure the most current guidelines are followed. Supplies appropriate documentation from the medical record and coding information from expert sources. Reports outcome to management and Coding Resources Advisors.
Identifies trends/patterns that could pose a compliance risk or reimbursement issue and reports them to Coding Resources Management and Coding Resources Advisor for coding and documentation education, trending, and monitoring.
• Researches, analyzes, and resolves government- and third-party-payer coding-related per-bill scrubber edits.
Works closely with Patient Financial Services and management to improve claim edits in all billing systems in order to keep coding-related denials to a minimum. Works claims daily and maintains daily goals and quality.
• Identifies and reports any regulatory or compliance concerns to the Coding Resources Manager. Monitors coding-related audit activity in the organization’s tracking tool. Works in conjunction with the Clinical Coding Specialist and Coding Advisors to review all coding-related external audit determinations. Apply clinical and coding assessment skills to medical records and extract supportive documentation for appeals. Report any issues to the department managers and the compliance team. Provide clinical documentation education to appropriate staff and physicians. Communicate with outside agencies when necessary to clarify issues.
• Provides education to the Coding Resources team members based on audit, edit, and denial research findings.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.
• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
Minimum Qualifications
Education
• High school graduate or equivalent
Experience
• Minimum two years of experience in a multi-specialty clinic and/or hospital working with ICD-CM, CPT-4/HCPCS coding, billing, fees, and reimbursement.
• Demonstrated ability to understand and develop information using databases and create complex spreadsheets. Intermediate knowledge of Microsoft Office products, including Word, Excel, and PowerPoint.
Certifications and Licenses
• Credential as Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC) or Certified Coding Specialist (CCS), or other AHIMA or AAPC recognized coding credentials
Or an equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered. Employees that require a licensed or certification must be properly licensed/certified and the licensure/certification must be in good standing.
