Manager Coding Quality Risk

Job Description

Job Description

OVERVIEW OF POSITION :

This function provides coding and coding auditing services directly to providers. This includes the analysis and translation of medical and clinical diagnoses, procedures, injuries, or illnesses into designated numerical codes.

Demonstrates experience by correlating coding accuracy with correct HCC assignment for MA / Risk and / or CPT, ICD-10, HCPCS and Modifiers for FFS.

Complies with all aspects of Coding and Corporate Compliance standards. Abides by all ethical standards and adheres to official coding guidelines.

ESSENTIAL FUNCTIONS :

• Develops overarching strategies for the analytical and specialized coding processes for the department.
• Sets the fundamental direction of executing these strategic plans with the team.
• Manages, guides, and supports the overall work of the team to maximize results by providing subject matter expertise and training.
• Oversees work activities of others (e.g., staff, team leads, supervisors) and is the point of contact for escalated coding related matters and concerns.
• Adapts departmental plans and priorities to address business needs and operational challenges.
• Gathers relevant data and analyzes information to resolve complex billing / coding issues and determine the root cause for coding discrepancies.
• Reconcile discrepancies identified on coding correction and held voucher reports.
• Generate and / or distribute reports and documentation to leadership team and / or ancillary departments.
• Demonstrate understanding of relevant systems and coding software applications (e.g. Practice Management Systems, EMRs, MS Office, Medical Coding software)
• Leverage understanding of disease process to identify and extract relevant details and data within clinical documentation and make determinations or identify appropriate medical codes.
• Utilize resources and reference materials (e.g., on-line sources, manuals) to identify appropriate medical codes and reference code applicability, rules, and guidelines
• Apply understanding of relevant medical coding subject areas (e.g., diagnosis, procedural, evaluation and management, ancillary services) to assign appropriate medical codes
• Apply understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable medical codes
• Identify areas in clinical documentation that are unclear or incomplete and generate queries to obtain additional information.
• Follow up with providers as necessary when responses to queries are not provided in a timely basis
• Read and interpret medical coding rules and guidelines to make decisions (e.g., exclusions, sequencing, inclusions)
• Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current HCC and / or CPT-4, HCPCS II, and ICD-10 materials, the Federal Register, and other pertinent materials.
• Make determinations on medical charting and take initiative to complete reviews independently to avoid delays in the process
• Manage multiple work demands simultaneously to maintain relevant productivity and turnaround time standards for completing medical records (e.

g., charts, assessments, visits, encounters)

• Resolve medical coding edits or denials in relation to code assignment
• Perform medical coding audits to evaluate medical coding quality and review results
• Provide information or respond to questions from medical coding quality audits and utilize results to identify potential corrections / enhancements to the coding processes.
• Follow steps per agreement with medical coding audit results to resolve discrepancies
• Provide resources and information to substantiate medical coding audit findings
• Educate and mentor others to improve medical coding quality
• Apply understanding of National Correct Coding Edits to the coding process
• Demonstrate understanding of National and Local coverage determinations
• Demonstrate basic knowledge of the impact of coding decisions on revenue cycle
• Demonstrate understanding of relevant terminology required for coding
• Follow relevant professional code of ethics consistent with required certifications
• Attain and / or maintain relevant professional certifications and continuing education seminars as required
• Uses, protects, and discloses patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Ability to travel may be required.

EDUCATION :

• Undergraduate degree or equivalent experience.
• AAPC or AHIMA approved coding certification program.
• CPC, CRC or RHIT certification

EXPERIENCE : Minimum :

Minimum :

• Must have 3-5 years of coding experience in a Primary Care / Specialty environment.
• 3+ years of Management experience

Preferred :

• Primary Care Physician coding experience
• Risk Adjustment / HCC coding experience
• Knowledge of Fee for Service, Medicare, Medicare Advantage, and Health Maintenance Organization (HMO) payer guidelines
• Experience working within an EMR

KNOWLEDGE, SKILLS, ABILITIES :

• Ability to oversee the daily responsibilities of the Coding department, while setting goals and priorities for the team.
• Must have an excellent understanding of medical terminology, disease process and anatomy and physiology.
• Must have an excellent understanding of ICD-10-CM coding classification and guidelines.
• Must have an excellent understanding of CPT, HCPCS and Modifiers coding and guidelines within a primary care environment.
• Must have Computer skills (i.e. MS Office, Power Point).
• Must have good organizational and communication skills.
• Must be task oriented and able to meet designated deadlines and productivity standards.
• Must have strong Interpersonal skills and excellent Customer Service skills.
• Ability to present a professional image when interacting with all levels of staff.
• Ability to write reports, business correspondence and procedures.
• Ability to effectively present information and respond to questions from government entities, employees, leadership team, and physicians
• Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations
• Ability to recognize, evaluate, solve problems, and correct errors, and to develop processes that eliminate redundancy
• Ability to work under minimum supervision and demonstrate strong initiative
• Ability to deal in an organized manner with problems involving multiple variables within the scope of the position
• Ability to make independent decisions when circumstances warrant; make prompt and accurate judgments regarding Coding and other office duties
• Ability to conceptualize workflow, develop plans, and implement appropriate actions
12 days ago