Job description

SUMMARY

Under the general direction of Coding/Auditor Supervisor The Coding/Auditor Specialist evaluates the adequacy and effectiveness of coding and documentation on claims payments internal and operational controls designed to ensure that coding processes and practices lead to appropriate execution of regulatory requirements and guidelines related to facility coding including federal and state regulations and guidelines, CMS (Centers for Medicare and Medicaid Services) and OIG (Office of Inspector General) compliance standards. Applies standardized scoring methodology to consistently evaluate coding accuracy and standardizes review findings and methodology to report monitoring results. Communicates review results to department management, coders, and other appropriate staff. Makes recommendations to management for corrective action. Serve as a subject matter expert and authoritative resource on interpretation and application of coding rules and regulations and conducts risk assessments of potential and detected compliance deficiencies.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Adheres to the defined review timeline and coding review protocol standards; assists with development of the monitoring schedule; identifies areas to be reviewed.
• Applies consistent and standardized compliance monitoring methodology for sample selection, scoring and bench marking, development, and reporting of findings.
• Conducts risk assessments to define monitoring priorities by evaluating previous findings.
• Conducts routine retrospective and prospective facility and technical coding reviews, specialized and focused reviews, and other reviews as directed by the Supervisor and Manager.
• Evaluates the appropriateness of ICD-10(International Classification of Diseases), HCPCS (Healthcare Common Procedure Coding System) and CPT (Current Procedural Terminology) codes; evaluates the appropriateness of DRG (Diagnosis-related Group) and admission assignments; evaluates appropriateness of modifier usage; and performs other related analysis and evaluations.
• Prepares written reports of review findings and recommendations and presents to management and maintains monitoring records.
• Researches, abstracts, and communicates federal, state, and payor documentation, and coding rules and regulations; stays current with Medicare, Medi-Cal and other third-party rules and regulations, ICD and CPT coding updates, Coding Clinic guidelines; serves as subject matter expert and authoritative resource for the department.
• Audits and documents pre-check runs based on established and ad-hoc check run schedules.
• Identifies and resolves various claims issues, documents, and reports results prior to every check run.
• Resolves identified claims issues based on CCI edit report to comply with CMS guidelines.
• Identifies and escalates issues related to instructional material that is inaccurate, unclear, or contains gaps. Provides recommendations for correction of this material. Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.

QUALIFICATIONS:

· Minimum of 3+ years of progressively responsible and related work experience."

· CPC Certification

· Experience working with Medicare / Medicaid / Managed Care claims

· Knowledge of healthcare regulations and guidelines including.

· CMS

· DMHC

· DHCS guidelines

· Proficiency with Excel

· Associate degree (AA) or 2 - 3 years of related experience and/or training; or equivalent combination of education and experience.

· Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding.

· Intermediate skill levels in Microsoft Word, Excel, and Outlook preferred.

· Ability to author routine reports and correspondence.

· Ability to speak effectively before groups of customers or employees of the organization.

· Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra.

· Ability to apply common sense understanding to carryout instructions furnished in written, oral, and diagram form.

· Ability to deal with problems involving several concrete variables in standardized situations.

• Knowledge of health information systems for computer application to medical records
• Knowledge of ICD-10-CM & CPT-4 coding conventions to code medical record entries; abstract information
• from medical records, read medical record notes, and reports; set accurate Diagnostic Related Groups
• Knowledge of standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of disease

TECHNICAL REQUIREMENTS

· Knowledge and experience with Microsoft Word, and Outlook software.

· Must be willing to learn applicable computer programs.

BEHAVIORAL REQUIREMENTS

· Demonstrate accountability for one’s own actions.

· Complete routine and priority tasks within departmental time frames.

· Convey care when answering phone calls and assisting customers.

· Demonstrate the ability to effectively interact with both external and internal customers in demanding situations.

· Demonstrate ability to make sound decisions.

· Demonstrate accountability for one’s own actions.

· Complete routine and priority tasks within departmental time frames.

· Convey care when answering phone calls and assisting customers.

· Maintain confidentially when managing sensitive material.

LANGUAGE SKILLS

Proficiency in speaking, reading, and writing English is required. Speaking Spanish, Vietnamese, Chinese and/or Tagalog is desirable but not required.

PHYSICAL DEMANDS

· The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

· While performing the duties of this position, the employee is regularly required to sit, 90% of the workday, stand infrequently, use a computer keyboard frequently and intermittently throughout the day, and use hands to finger, handle, or feel objects, tools or controls. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to walk.

· The employee must be able to infrequently lift and move up to twenty-five pounds. Specific vision abilities required by this position include close vision, color vision and the ability to adjust focus.

· Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Job Type: Full-time

Pay: $27.50 - $32.04 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

COVID-19 considerations:
We follow the Santa Clara County Public Health guidelines

Ability to commute/relocate:

• San Jose, CA 95131: Reliably commute or planning to relocate before starting work (Required)

Experience:

• ICD-10: 1 year (Preferred)

Work Location: In person

Please Note :
epokagency.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, epokagency.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.