Claim Review Specialist – Coding Certification Required

Responsibilities

• Assist the Director of HIM in preparing claim audits, reviewing and recommending coding, revenue cycle and charge/billing changes on client hospital outpatient and Profee claims using proprietary software product.
• Use software to develop standardized reports, meet with clients, respond to coding questions in clear, concise, grammatically correct English, and provide support for other members of the revenue cycle consulting team.
• Client education, written FAQ answer preparation, and other duties as assigned.
• Become proficient in the use of the PARA Data Editor, our proprietary software; select and review claims for review based on trends/data analysis in the PARA Data Editor; organize information and access to medical documentation.
• Audit all aspects of claim including (but not limited to): -Omitted or incorrect charges, -Review OPPS and CAH charges and apply guidelines.
• CMS/Payer specific guidelines -Coding accuracy for ICD-10 CM, CPT/HCPCS (including but not limited to , 80000, 90000, J codes, G codes, Q codes,etc).
• Departmental review for inaccuracies, omitted data/documentation and charges -NCCI edits, MUE edits, Medi-cal and Medicare guidelines/CMS Manual guidance, -Units of services -E/M Profee/Facility -Units of services -Documentation improvement.
• Assist in preparing written documents for publication under the direction of the Director, HIM, i.e., Q&A entries.
• Develop a working understanding of the outpatient hospital reimbursement process, including documentation, coding, and billing.
• Participate in presentations to clients and prospective clients, typically over web meetings.
• Develop and maintain the skills and knowledge necessary related to the assigned specialty areas and the related services.

Requirements

• Active AAPC or AHIMA coding certification (CPC, COC, CIC, CCS, RHIT, RHIA) - cannot be "apprentice" certification (i.e.: CPC-A)
• Coding and/or auditing experience - OP facility (ER, I&I, OBS, SDS, E/M facility) and Profee; IP facility coding is a plus.
• 5+ years of current directly related experience.
• Expert knowledge in revenue cycle and Outpatient coding (ER, SDS, OBS, ancillary, IR, Profee, E/M facility, I&I).
• CCS, COC or CPC certification required.
• Medical Terminology and anatomy knowledge is required.
• Clinical Documentation and Inpatient coding experience is preferred.
• Strong understanding of revenue cycle, CMS Manual/guidelines, Medicaid guidelines.
• Strong Microsoft Excel, PowerPoint, Word and OneNote skills.
• Strong understanding of the Official Coding Guidelines, OP coding and billing (i.e. including but not limited to knowledge of rev codes, HCPCS, MUE and CCI edits, UoS and ICD-10 CM).
• Strong analytical capability, independent thinker and good decision-making skills.
• Excellent written and verbal communication and presentation skills.
• Strong computer and technology knowledge and skills.
• Highly professional demeanor, great client satisfaction skills.

Core Competencies

Proficient in outpatient coding and revenue cycle management, with expertise in ICD-10 CM, CPT/HCPCS coding, and a strong understanding of CMS and Medicaid guidelines. Demonstrates excellent analytical, communication, and client education skills while utilizing proprietary software for claim audits and reporting.