What are the responsibilities and job description for the HIS - Provider Review & Education Specialist - 40 hrs/wk, 1st shift position at Blanchard Valley Health System?
PURPOSE OF THIS POSITION
The Provider Review and Education Specialist serves as a subject matter expert and key resource for provider documentation integrity supporting professional fee coding, risk adjustment documentation and denial prevention. This position conducts provider-focused documentation and coding reviews, identifies trends and opportunities, and develops targeted education. This position collaborates and serves as liaison between physicians, advanced practice providers, coding and clinical documentation improvement (CDI) teams, compliance, revenue integrity, clinical leadership, denials management, and value-based care stakeholders to improve documentation integrity, coding quality, regulatory compliance, and sustained provider engagement.
Job Duties/Responsibilities
Duty 1: Conducts provider documentation and coding reviews in accordance with approved review plans, departmental procedures, and risk-based prioritization criteria, including baseline reviews, focused reviews, onboarding reviews, scheduled periodic reviews, and follow-up reviews after education.
Duty 2: Reviews professional fee encounters comparing provider documentation, codes, charges, modifiers, and other relevant billing elements to applicable coding guidelines, payer rules, medical necessity requirements, professional billing policies, and regulatory standards.
Duty 3: Supports the development and optimization of provider documentation note templates, coding tools, and EHR workflows with coding, compliance, clinical operations, and informatics teams to improve documentation consistency, coding accuracy, compliant charge capture, HCC capture and point-of-care documentation quality.
Duty 4: Documents review results accurately and objectively, including education completion, provider questions, coding changes, denial patterns, modifier usage, E/M utilization, and other indicators to identify recurring themes and prioritize future education.
Duty 5: Develops and delivers provider feedback and educational tools that are clear, concise, and aligned with provider specialty, documentation patterns, and practice needs (i.e., presentations, quick-reference guides, coding updates, tip sheets, onboarding materials, specialty-specific examples, newsletters, or frequently asked questions).
Duty 6: Supports new provider onboarding by providing initial education on documentation and coding expectations, completing early reviews as assigned, and providing timely feedback to support accurate documentation and charge capture.
Duty 7: Collaborates with coding leadership, coding auditors and educators, practice leaders, clinical managers, compliance, revenue integrity denials, IT, CDI, value-based care, and physician champions to align education efforts and resolve process-related barriers.
Duty 8: Participates in denials prevention efforts by applying knowledge of coding guidelines, payer requirements, medical necessity criteria, documentation standards, and denial root causes to identify provider documentation trends, support denial prevention education, and collaborate with coding, revenue integrity, CDI, compliance, and operational stakeholders on process improvement opportunities.
Duty 9: Prepares reports and summary materials for leadership, governance committees, and stakeholders that communicate review activity, education outcomes, trends, risks, progress, and recommended next steps.
Duty 10: Ensures compliance with regulatory requirements, including CMS, OIG, payer contracts, AHIMA and AAPC Standards of Coding Ethics, HIPAA, and internal policies.
Duty 11: Maintains professional certification, continuing education, and current knowledge of coding, documentation, compliance, payer, and healthcare industry changes relevant to the position.
Duty 12: This job description reflects the general nature and expectations for the position. It is not an exhaustive list of activities, duties, or responsibilities involved. The incumbent may be asked to perform other related duties as needed.
Required Qualifications
This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.
The Provider Review and Education Specialist serves as a subject matter expert and key resource for provider documentation integrity supporting professional fee coding, risk adjustment documentation and denial prevention. This position conducts provider-focused documentation and coding reviews, identifies trends and opportunities, and develops targeted education. This position collaborates and serves as liaison between physicians, advanced practice providers, coding and clinical documentation improvement (CDI) teams, compliance, revenue integrity, clinical leadership, denials management, and value-based care stakeholders to improve documentation integrity, coding quality, regulatory compliance, and sustained provider engagement.
Job Duties/Responsibilities
Duty 1: Conducts provider documentation and coding reviews in accordance with approved review plans, departmental procedures, and risk-based prioritization criteria, including baseline reviews, focused reviews, onboarding reviews, scheduled periodic reviews, and follow-up reviews after education.
Duty 2: Reviews professional fee encounters comparing provider documentation, codes, charges, modifiers, and other relevant billing elements to applicable coding guidelines, payer rules, medical necessity requirements, professional billing policies, and regulatory standards.
Duty 3: Supports the development and optimization of provider documentation note templates, coding tools, and EHR workflows with coding, compliance, clinical operations, and informatics teams to improve documentation consistency, coding accuracy, compliant charge capture, HCC capture and point-of-care documentation quality.
Duty 4: Documents review results accurately and objectively, including education completion, provider questions, coding changes, denial patterns, modifier usage, E/M utilization, and other indicators to identify recurring themes and prioritize future education.
Duty 5: Develops and delivers provider feedback and educational tools that are clear, concise, and aligned with provider specialty, documentation patterns, and practice needs (i.e., presentations, quick-reference guides, coding updates, tip sheets, onboarding materials, specialty-specific examples, newsletters, or frequently asked questions).
Duty 6: Supports new provider onboarding by providing initial education on documentation and coding expectations, completing early reviews as assigned, and providing timely feedback to support accurate documentation and charge capture.
Duty 7: Collaborates with coding leadership, coding auditors and educators, practice leaders, clinical managers, compliance, revenue integrity denials, IT, CDI, value-based care, and physician champions to align education efforts and resolve process-related barriers.
Duty 8: Participates in denials prevention efforts by applying knowledge of coding guidelines, payer requirements, medical necessity criteria, documentation standards, and denial root causes to identify provider documentation trends, support denial prevention education, and collaborate with coding, revenue integrity, CDI, compliance, and operational stakeholders on process improvement opportunities.
Duty 9: Prepares reports and summary materials for leadership, governance committees, and stakeholders that communicate review activity, education outcomes, trends, risks, progress, and recommended next steps.
Duty 10: Ensures compliance with regulatory requirements, including CMS, OIG, payer contracts, AHIMA and AAPC Standards of Coding Ethics, HIPAA, and internal policies.
Duty 11: Maintains professional certification, continuing education, and current knowledge of coding, documentation, compliance, payer, and healthcare industry changes relevant to the position.
Duty 12: This job description reflects the general nature and expectations for the position. It is not an exhaustive list of activities, duties, or responsibilities involved. The incumbent may be asked to perform other related duties as needed.
Required Qualifications
- College degree in a related field including, but not limited to health information management, a clinical profession, or 5 years of experience from which comparable knowledge and abilities have been acquired.
- Certified Professional Coder (CPC), Certified Coding Specialist- Physician Based (CCS-P), or Certified Coding Specialist (CCS) with professional coding experience required.
- Certified Documentation Expert Outpatient (CDEO) or Certified Risk Adjustment Coder (CRC) required or eligible with completion expected within twelve months of employment or entering into position.
- Possess advanced understanding of coding classification systems CPT, HCPCS, ICD-10-CM, etc., and thorough knowledge of revenue cycle and reimbursement processes.
- Ability to review medical record documentation, identify coding and documentation variances, interpret findings, and translate complex guidance into practical provider education.
- Strong knowledge of risk adjustment concepts, including HCCs, RAF scores, and MEAT criteria, with experience educating providers, identifying documentation trends, and supporting provider documentation improvement initiatives that promote accurate chronic condition capture, value-based care reporting, and appropriate reimbursement.
- Knowledge of healthcare quality measures, including HEDIS and other value-based care metrics, and their relationship to documentation, coding accuracy, gap closure, and quality reporting.
- Proficiency in provider documentation-based charge capture, including documentation review, note template optimization, coding tool utilization, and workflows that support accurate coding, compliance, and revenue integrity.
- Strong knowledge of regulatory and compliance requirements; a bility to seek out and research coding related topics through resources such as Coding Clinic, CPT Assistant, CMS websites, etc.
- Excellent written, verbal, presentation, facilitation, and interpersonal communication skills, including the ability to provide constructive feedback to physicians, advanced practice providers, and clinicians. Ability to build trust and credibility.
- Ability to work independently and meet deadlines.
- Capable of managing multiple tasks/projects with excellent organizational, time management, and prioritization skills. Self-motivated.
- Proven proficiency with computer applications, including Microsoft Office (Excel, Word, PowerPoint), and technology solutions that facilitate review workflows, data analysis, quality monitoring, and operational reporting.
- Thrives in a fast-paced, creative environment, moving independently between tasks.
- Makes sound decisions quickly, maintains professional conduct, and works well with others on both individual and team levels.
- Hybrid work position with travel required between medical practices in the BVHS service area.
- A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within 30 days of your residency in the state). You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
- Additional credentials such as Certified Professional Medical Auditor (CPMA), Certified Evaluation and Management Coder (CEMC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or another clinical licensure.
- Experience developing provider education materials, specialty-specific documentation tools, E/M education, denial prevention education, onboarding programs, and remediation workflows.
- Ability to analyze trends, prepare executive summaries, and present findings to provider-based audiences, leadership, compliance, and governance committees.
- Familiarity with EHR workflows (e.g., Cerner, Epic), Solventum/3M encoder, data warehouse environments, reporting dashboards, or review-tracking software.
This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.