Advocate Aurora Health
TELECOMMUTE – Milwaukee, WI
Title:Hospital Coding Quality Specialist – Remote
Full/Part Time:Full Time
Benefits Eligible: Yes
Hours / bi-weekly pay period:80
Responsible for completing hospital coding accuracy reviews to assist coding leadership in carrying out the department’s compliance plan to ensure that our coding team members are coding accurately according to the documentation within each record, validating accurate external reporting and appropriate reimbursement.
Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for outpatient, day surgery and inpatient records. Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions.
Works collaboratively with coding leadership per their direction in reviewing records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may give visibility into documentation that is driving codes.
Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed.
Identifies coder education opportunities, team trends, and consideration of topics to mandate for second level account review, before the account is final coded.
Reviews encounters flagged for second level review, including but not limited to; hospital acquired conditions (HACs), complications and other identified records such as core measures or trends as identified by coding leadership. Perform review of coded encounter for appropriate risk-adjustment, including accurate severity and risk of mortality assignment.
Responsible for coding participation in the Clinical Documentation Improvement and Hospital Coding alignment process. Review accounts with mismatched DRG assignment following notification from the Inpatient coder. Determine the appropriate DRG based on coding guidelines. Provide follow up to the clinical documentation nurse with rationale on final outcome. Recommends educational topics for coders and clinical documentation nurses based on their observations from reviewing mismatches.
Participate in hospital coding denial and appeal processes as directed. Ensure timely review and response to any third-party payer notification of claims where codes are denied. Determine if an appeal will be written based on application of coding guidelines and provider documentation.
Following review of overpayment or underpayment denials, provide appropriate follow-up to coding team member as appropriate, rebilling accounts to ensure appropriate reimbursement. All trends identified should be presented to coding leadership in a timely manner and logged for historical tracking purposes.
Investigates and resolves all edits or inquiries from the billing office or patient accounts, to prevent any delay in claim submission due to open questions related to coding. Identifies any coding issues as they relate to coding practices. Clarifies changes in coding guidance or coding educational materials.
Maintains continuing education credits and credentials by keeping abreast of current knowledge trends, legislative issues and/or technology in Heal…
Insurance Claims , Medical & Health , Medical Coding