With minimal supervision directly supports the following responsibilities of the Coding and documentation quality assurance (CDQA) team: implementation of and compliance to enterprise-wide and department coding policies and procedures for PHS; compliance to all external regulatory agency coding rules and regulations; Demonstrates high-level of proficiency in performing and/or managing on-site internal audits or reviews to assess compliance/quality monitoring performed by PHS/PMG departments while serving as a resource on documentation, coding, billing, and coding compliance questions. Works on special coding compliance related projects, develops and presents educational programs, disseminates information to PHS/PMG departments and develops educational tools used to maintain compliance with regulations. Provides support via auditing and training the enterprise-wide corrective action plans for coding, audit, physician and clinician personnel identified as low performers; perform medical record and billing reviews of denied and appealed claims and takes appropriate action to ensure accurate payment of claims; coordinate review and tracking of appealed claims including the communication process with affected payers; research and interpret all regulatory agency regulationsType of Opportunity: Full timeJob Exempt: YesJob is based: Remote Workers New MexicoWork Shift: Days (United States of America) Responsibilities:
Liaison to the Manager, Information Services, Finance/Patient Financial Services, all hospitals, all PMG sites, PHP, Home Health, Albuquerque Ambulance, Compliance and all ancillary departments in addressing functional coding, auditing, compliance and training issues and problems. Interacts with all levels of management responsible for maintaining accurate, complete and timely documentation in either electronic or hard copy form
Must be able to adapt to frequently changing work priorities and schedules. Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-9, ICD-10, CPT-4, HCPCS and APC updates and changes
Researches coding, billing and charging compliance issues, recommends and implements corrective action plans that assure compliance with regulatory agencies where appropriate. Identifies risks, develops and follows up on action plans, identifies lost revenue opportunities and any overpayments due to errors in coding and/or documentation, and provides compliance education
Assists in the creation of the CDQA Annual Audit Work-plan by utilizing the OIG work plan, Medicare and Medicaid regulations, RAC and other audit agency focuses, as well as internal and external risk assessments
Regularly exercises independent judgment in determining the reliability of data reviewed; recommends changes in existing practices to gain or maintain compliant behavior. Keeps actively informed on the business climate of the healthcare industry
Responds to inquiries and requests daily regarding coding and auditing issues and problems and ad-hoc analysis for all PHS management
Maintains up-to-date working knowledge of all PHS coding and auditing IT applications
Gathers and analyzes information and provides recommendations to address and resolve business issues for a specific business group
Conducts training classes in areas of coding, documentation and compliance for PHS/PMG personnel. This includes preparation of training materials, educational audits and answering specific situational questions, ICD-10 education and EPIC EMR documentation education to providers and clinical staff
Conducts systematic focused internal audits via medical record and charge ticket review to insure correct coding, billing and charging as member of CDQA audit team
Analyzes and summarizes data from medical record and account audits and communicate results and findings to management and complianceDevelops new methods and processes to improve coding efficiency and effectiveness
Researches and investigates external and internal customer concerns regarding patient care and/or billing of patient care. Ensures that coding functions are performed in accordance with established quality and performance standards by monitoring system generated reports and quality audits
Working hours may vary based on projects assigned Must be able to travel to all of the PHS/PMG sites (including overnight). Travel varies at certain times based on assignments
Qualifications:
High school diploma/GED required. Must possess at least one of the following license/certifications: RHIT, RHIA, CPC, CCS and a minimum of three (3) years experience in coding and/or auditing required. Audit experience preferred. Excellent written and verbal communication skills. . Excellent written and verbal communication skills. Detail and results oriented. Ability to work independently and make independent decisions. Medical terminology, ICD-9, CPT-4 and HCPCS knowledge required.
Must have a proficient knowledge of Medicare, Medicaid, and other third party payer documentation, coding, and billing regulations for service lines(s) assigned.
Must possess excellent organizational and planning skills, including the ability to prioritize multiple tasks and perform them both accurately and simultaneously.
Must possess computer skills, especially with Microsoft Word, PowerPoint, and Excel applications. Must be able to use the internet and other resource applications for research purposes and to provide documentation that supports regulations quoted in audits.
Must possess strong written and verbal communication skills in order to communicate in clear, concise terms to management at all levels, including the ability to articulate complex regulatory information in laymans terms.
Must possess a personal presence of a highly qualified professional that is characterized by a sense of honesty, integrity, and the ability to inspire and motivate others.
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services Originally posted on Himalayas