HIM Clinical Data Quality Auditor and Educator

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Job Summary:

Responsible for hospital coding quality and standards development for ICD-10-CM/PCS, CPT, and HCPCS codes for the Health Information Management department. This includes performing internal audits, overseeing external audits, and providing education and training to the hospital coders. Responsible for working with other hospital departments to resolve all coding issues that prevent accounts from being processed appropriately. Responsible for developing, implementing and maintaining compliance plan for hospital coding and abstracting. Responsible for participating in system administration maintenance duties for coding and abstracting software.

Position Responsibilities:

Training and Education:

Providing training and education for newly hired coders; checking their coding, abstracting, and querying; tracking their progress; and auditing their work once they are released. Developing coding and training resources for the entire coding team (modules, scenarios, tip sheets, etc.). Assisting in the coordination, synchronization, and reconciliation between CDI specialists and coders. Assisting in educating, monitoring, and reporting on productivity and quality standards. Researching and responding to daily questions from all coders regarding the correct application of coding guidelines for complex accounts.

Review and Resolution of Interdepartmental Coding-related Issues:

Working closely with Patient Accounting, Case Management, Quality Management, and other hospital departments to resolve coding and reimbursement issues. Serving as an escalation point and answering questions regarding coding requirements. Providing education to their staff, including physicians and physician billers, on hospital coding billers. Recommending changes to policies, procedures, charge master and documentation requirements to insure appropriate reimbursement

Auditing:

Performing audits to monitor coding and abstracting quality and compliance. Performing specialized audits to facilitate quality improvement and compliance (RAC, PEPPER, OIG initiatives). Processing external quality audits, which includes distributing results, preparing rebuttals/appeals, and taking appropriate action with responses (including correcting data and educating coders). Reviewing and responding to Payor Audits involving DRG and coding changes. Providing feedback with recommendations for improvement.

Accounts Receivable:

Assisting with monitoring of hospital Discharge Not Final Billed reports. Troubleshooting and resolving complex problems with individual accounts in order to facilitate appropriate reductions in A/R and accounts held for coding. Coding charts when urgently needed to facilitate A/R goals. Working closely with all campuses to provide efficiencies in operational coding workflow, adjustment in workflow queues, etc.

Policies and Procedures:

Developing policies and procedures on coding, data abstraction and Corporate Compliance for Health Information Management. Documenting and enforcing policies and procedures for HIM, and providing feedback to appropriate supervisors and/or staff.

Coding, abstracting and state data system maintenance:

Maintaining and updating systems to collect accurate data for billing and state data collection, as well as hospital statistical requirements. Identifying and resolving problems with the assistance of IS and vendor counterparts. Designing testing tools and participating in testing and validation of code sets, coding and abstracting programs. Supporting scheduled and unscheduled system upgrades. Managing downtime, and putting back-up plans into place.

Position Qualifications Required:

Required Experience:

3 years hospital inpatient and outpatient experience required

Experience with multiple service lines preferred (cardiac, obstetrics, orthopedics, medical-surgical, etc.)

Knowledge of PC database applications, Microsoft Office, spreadsheet design, encoder required.

Subject matter expertise in the areas of ICD-10-CM and PCS, CPT-4, DRGs, APCs and CMI required.

Ability to develop and present education presentations required

Required Education:

Bachelor or Associates Degree in HIM, or Coding Certificate Program, or equivalent experience, leading to appropriate certification.

Training / Certification / Licensure:

Certification as CCS by AHIMA

RHIA/RHIT certification preferred