Coding Integrity Specialist

ESSENTIAL FUNCTIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Work coding claim edits

Review CCI edits and documentation to determine if modifiers are appropriate

Review claims edits for medical necessity. Review documentation for supporting diagnosis codes.

Review claim edits for MUE’s (Medically Unlikely Edits) and determine appropriate correction

Review claim edits to determine if claim should be sent to different queue

Trend claim edit errors

Maintain data on edits to identify trending to be used coder education sessions as well as performance reviews

Compile user friendly Denials Management Report from Qlik Denials Management Report to aid in determining true, preventable denials that we can put into an action plan to decrease such denials

Build and maintain a shared folder of payer policies for coding and medical necessity to aid in decreasing claim edits and denials based on these policies ICD-10 and CPT/HCPCS coding

Help build and maintain reference manuals for ER, IC, WC, IP, OBS, clinic specifics to ensure consistency when cross-training or hiring new coders.

Person hired would not have to be a certified coder but need billing and medical experience.

Any other assigned duties.

ADDITIONAL RESPONSIBILITIES:

KNOWLEDGE/SKILL/ABILITIES:

AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.

INFORMATION MANAGEMENT: Treats all information and data within the scope of the position with appropriate confidentiality and security.

RISK MANAGEMENT/QUALITY MANAGEMENT/SAFETY: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

MINIMUM POSITION QUALIFICATIONS:

• Education – High School Diploma

• Work Experience – Billing & Coding knowledge preferred.

• Candidate - Person is encouraged to become a certified coder as claim edits become less, denials become less, pending clinic accounts become less and this position only maintains payer policy manual and reference manual they would be able to fill in for any attrition and/or be back up for PTO or as services grow.

ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.

PHYSICAL REQUIREMENTS: Sitting for long durations.