Clinical Coder

Job Summary

Under the direction of the DRG Supervisor or designee, conducts coding review of prior authorization requests for unlisted codes or services; retrospective medical claims review for coding and pricing determinations; and / or coding review for inpatient (facility) claims to include diagnosis and procedural coding with DRG assignment. Provides coding-related information to medical directors, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed.. Develops determination letters. Provides support to non-clinical and clinical staff on coding and pricing and retrospective medical claims review processes.

Education & Experience

Required :

• High School Diploma or GED
• Current Certification as a Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Registered Health Information Technician (RHIT)
• U.S. Citizen
• Must be able to receive a favorable interim and adjudicated final Department of Defense (DOD) background investigation.
• Minimum 2 years of clinical coding experience for either outpatient and / or inpatient accounts
• Minimum 2 years of claims processing experience in outpatient and / or inpatient accounts

Preferred :

Key Responsibilities

Competencies

Communication / People Skills : Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy : Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility : Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Independent Thinking / Self-Initiative : Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management : Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Organizational Skills : Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis : Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Team-Building / Team Player : Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills : Knowledge of ICD-10-CM, ICD-10-PCS, CPT and HCPCS coding; ability to maintain the confidentiality and security requirements of medical records; ability to meet department performance standards.

Working Conditions

Working Conditions :